Professional Documents
Culture Documents
PROCEDURE MANUAL
for PCL course
Nursing Department,
Khwopa Poly-Technic Institute
Japan International Cooperation Agency (JICA)
Published by:
Japan International Cooperation Agency (JICA) Nepal Office
Block B, Karmachari Sanshaya Kosh Building
Hariharbhavan, Lalitpur, NEPAL
(P.O. Box 450, Kathmandu, NEPAL)
Tel:(977-1) 5010310
Fax:(977-1) 5010284
Contributor:
Sanjita Khadka
Durgeshori Kisi
Padma Raya
Saphalta Shrestha
Assistant lecturer:
Durgeshori Kisi
Padma Raya
Sushila Chaudhari
Sunita Batas
Instructor:
Saphalta Shrestha
Sumitra Budhathoki
Sabitra Khadka
Thank for contributing your professional knowledge and experience. We would like to appreciate
to all our teachers and the former teachers, Ms. Junely Koju, Ms.Uttam Tara, and Ms. Rashmi
Joshi.
Table of Contents
I. Basic Nursing Care/ Skill
Bed making
a. Making an Un-occupied bed
b. Changing an Occupied bed
c. Making a Post-operative bed
2. Performing oral care
a. Assisting the client with oral care
b. Providing oral care for dependent client
3. Performing bed bath
4. Performing back care
5. Performing hair washing
6. Care for fingernails/ toenails
7. Performing perineal care
8. Taking vital signs
a. Taking axillary temperature by glass thermometer
b. Measuring radial pulse
c. Counting respiration
d. Measuring blood pressure
9. Performing physical examination
10. Care for Nasal-gastric Tube
a. Inserting a Nasal-Gastric Tube
b. Removal a Nasal-Gastric Tube
11. Administering Nasal-Gastric tube feeding
12. Cleaning a wound and Applying a sterile dressing
13. Supplying oxygen inhalation
a. Nasal Cannula Method
b. Mask Method: Simple face mask
1.
9
13
16
19
21
23
26
30
32
35
37
39
41
43
45
46
49
98
98
101
102
106
109
111
113
115
117
120
123
126
129
130
135
140
144
147
148
149
151
153
153
157
159
160
161
163
164
166
168
168
169
Appendix
171
References
181
Bed making
a. Making an Un-occupied Bed
Definition:
A bed prepared to receive a new patient is an un-occupied bed.
Purpose
1. To provide clean and comfortable bed for the patient
2. To reduce the risk of infection by maintaining a clean environment
3. To prevent bed sores by ensuring there are no wrinkles to cause pressure points
Equipment required:
1. Mattress (1)
2. Bed sheets(2): Bottom sheet (1)
Top sheet
(1)
3. Pillow
(1)
4. Pillow cover (1)
5. Mackintosh (1)
6. Draw sheet (1)
7. Blanket
(1)
8. Savlon water or Dettol water in basin
9. Sponge cloth (4): to wipe with solution (1)
to dry
(1)
When bed make is done by two nurses,
sponge cloth is needed two each.
10. Kidney tray or paper bag (1)
11. Laundry bag or Bucket (1)
12. Trolley(1)
Rationale
Providing information fosters cooperation.
To prevent the spread of infection.
Organization
facilitates
accurate
skill
performance
It makes space for bed making and helps effective
action.
To maintain the cleanliness
11
Care Action
3) Tuck the mackintosh under the mattress.
4) Place the draw sheet on the mackintosh. Spread
and tuck as same as procedure 1)-3).
9.Move to the left side of the bed.
Bottom sheet , mackintosh and draw sheet:
1) Fold and tuck the bottom sheet as in the above
procedure 7.
2) Fold and tuck both the mackintosh and the draw
sheet under the mattress as in the above
procedure 8.
10. Return to the right side.
Top sheet and blanket:
1) Place the top sheet evenly on the bed, centering
it in the below 20-30cm from the top of the
mattress.
2) Spread it downward.
3) Cover the top sheet with blanket in the below 1
feet from the top of the mattress and spread
downward.
4) Fold the cuff (approximately 1 feet) in the neck
part
5) Tuck all these together under the bottom of
mattress. Miter the corner.
6) Tuck the remainder in along the side
11. Repeat the same as in the above procedure 10 in
left side.
12. Return to the right side.
Pillow and pillow cover:
1) Put a clean pillow cover on the pillow.
Rationale
Nursing Alert
Do not let your uniform touch the bed and the floor not to contaminate yourself.
Never throw soiled lines on the floor not to contaminate the floor.
Staying one side of the bed until one step completely made saves steps and time to do effectively and
save the time.
12
Bed making
b. Changing an Occupied Bed
Definition
The procedure that used lines are changed to a hospitalized patient is an occupied bed.
Purpose:
1. To provide clean and comfortable bed for the patient
2. T reduce the risk of infection by maintaining a clean environment
3. To prevent bed sores by ensuring there are no wrinkles to cause pressure points
Equipment required:
1. Bed sheets(2) : Bottom sheet( or bed cover) (1)
Top sheet
(1)
2. Draw sheet (1)
3. Mackintosh (1) (if contaminated or needed to change)
4. Blanket
(1) ( if contaminated or needed to change)
5. Pillow cover (1)
6. Savlon water or Dettol water in bucket
7. Sponge cloth (2): to wipe with solution (1)
to dry
(1)
When the procedure is done by two nurses, sponge cloth is needed two each.
8. Kidney tray or paper bag (1)
9. Laundry bag or bucket (1)
10. Trolley
(1)
13
Rationale
To assess necessity and sufficient condition
Providing information fosters cooperation
To prevent the spread of infection.
Organization facilitates accurate skill performance
To maintain the clients privacy.
To prevent personal belongings from damage and
loss.
The pillow is comfortable measure for the client.
14
Care Action
3) Tuck the bottom sheet tightly under the head of
the mattress and miter the corner.
4) Tighten the sheet under the end of the mattress
and make mitered the lower corner.
5) Tuck in along side.
6) Tuck the mackintosh and the draw sheet under
the mattress.
16. Assist the client back to the center of the bed.
Adjust the pillow.
17. Return to right side:
Clean top sheet, blanket:
1) Place the clean top sheet at the top side of the
soiled top sheet.
2) Ask the client to hold the upper edge of the clean
top sheet.
3) Hold both the top of the soiled sheet and the end
of the clean sheet with right hand and withdraw
to downward. Remove the soiled top sheet and
put it into a laundry bag (or a bucket).
4) Place the blanket over the top sheet. Fold top
sheet back over the blanket over the client.
5) Tuck the lower ends securely under the mattress.
Miter corners.
6) After finishing the right side, repeat the left side.
18. Remove the pillow and replace the pillow cover
with clean one and reposition the pillow to the
bed under the clients head.
19. Replace personal belongings back. Return the
bed-side locker and the bed as usual.
20. Return all equipments to proper place.
Rationale
21. Discard linens appropriately. Perform hand To prevent the spread of infection.
hygiene.
15
Bed making
c. Making a Post-operative Bed
Definition:
It is a special bed prepared to receive and take care of a patient returning from surgery.
Purpose:
1. To receive the post-operative client from surgery and transfer him/her from a stretcher to a bed
2. To arrange clients convenience and safety
Equipment required:
1. Bed sheets: Bottom sheet (1)
Top sheet (1)
2. Draw sheet (1-2)
3. Mackintosh or rubber sheet (1-2)
According to the type of operation, the
number required of mackintosh and draw
sheet is different.
4. Blanket (1)
5. Hot water bag with hot water (104- 140 )
if needed (1)
6. Tray1(1)
7. Thermometer,
stethoscope,
sphygmomanometer: 1 each
8. Spirit swab
9. Artery forceps (1)
10. Gauze pieces
11.
12.
13.
14.
15.
16.
17.
16
Rationale
To prevent the spread of infection
Organization
facilitates
accurate
performance
skill
4. Place top bedding as for closed bed but do not Tuck at foot may hamper the client to enter the
tuck at foot
bed from a stretcher
5. Fold back top bedding at the foot of bed. (Fig.10 ) To make the client s transfer smooth
6. Tuck the top bedding on one side only. (Fig. 11 )
Tucking the top bedding on one side stops the bed
linens from slipping out of place and
7. On the other side, do not tuck the top sheet.
The open side of bed is more convenient for
receiving client than the other closed side.
1) Bring head and foot corners of it at the center of
bed and form right angles. (Fig.12 )
2) Fold back suspending portion in 1/3 (Fig. 13 )and
repeat folding top bedding twice to opposite side
of bed(Fig.14, 15)
8. Remove the pillow.
To maintain the airway
9 Place a kidney-tray on bed-side.
To receive secretion
10. Place IV stand near the bed.
To prepare it to hang I/V soon
11. Check locked wheel of the bed.
To prevent moving the bed accidentally when the
client is shifted from a stretcher to the bed.
12.Place hot water bags(or hot bottles) in the Hot water bags (or hot bottles) prevent the client
middle of the bed and cover with fanfolded top if
from taking hypothermia
needed
13.When the patient comes, remove hot water bags To prepare enough space for receiving the client
if put before
14. Transfer the client:
1) Help lifting the client into the bed
2) Cover the client by the top sheet and blanket To prevent the client from chilling and /or having
immediately
hypothermia
3) Tuck top bedding and miter a corner in the end of
the bed.
17
18
Purpose:
1.
2.
3.
4.
5.
6.
Equipment required:
1.
2.
3.
4.
Tray (1)
Gauze-padded tongue depressor (1): to suppress tongue
Torch(1)
Appropriate equipments for cleaning:
- Tooth brush
- Foam swabs
- Gauze-padded tongue depressor
- Cotton ball with artery forceps (1) and dissecting forceps (1)
5. Oral care agents:
Tooth paste/ antiseptic solution
NURSING ALERT
You should consider nursing assessment, hospital policy and doctors prescription if there is,
when you select oral care agent. Refer to Table 1. on the next page
6. If you need to prepare antiseptic solution as oral care agent:
Gallipot (2): to make antiseptic solution(1)
to set up cotton ball after squeezed (1)
7. Cotton ball
8. Kidney tray (1)
9. Mackintosh (1): small size
10. Middle towel (1)
11. Jug with tap water (1)
12. Paper bag(2): for cotton balls (1)
for dirt(1)
13. Gauze pieces as required: to apply a lubricant
14. Lubricants: Vaseline/ Glycerin/ soft white paraffin gel/ lip cream (1)
15. Suction catheter with suction apparatus (1): if available
16. Disposable gloves( 1 pair): if available
19
NOTE:
Table 1. Various oral care agents for oral hygiene
The choice of an oral care agent is dependent on the aim of care. The various agents are available and should
be determined by the individual needs of the client.
Agents
Potential benefits
Potential harms
Tap water
To refresh
be available
Short lasting
not contain a bactericide
Tooth paste
Not specified
To remove debris
To refresh
Nystatin
Tastes unpleasant
Chlorhexidine gluconate:
a
compound
with
not be significant
to prevent
chemotherapy- induced mucositis *2
Tastes unpleasant
be stainable teeth with prolonged use
broad-spectrum
anti-microbial activity *2
Sodium bicarbonate:
Tastes unpleasant
may bring burn if not diluted
adequately
can alter oral pH allowing bacteria to
multiply *1
Fluconazole:
an
orally
absorbed
antifungal azole, soluble in
not reported
not reported
water
Sucralfate:
a mouth-coating agent
Glycerine an thymol
To refresh
Another solutions for oral care such as Potasium permanganate(1:5000), Sodium chloride(I teaspoon to a pint of
water), Potasium chroride( 4 to 6 %), Hydrogen perpxide(1: 8 solution) are used commonly*4.
References:
1. Penelope Ann Hilton(2004) fundamental nursing skills , I.K. International Pvt. Ltd., p.63
2.
3.
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7153&nbr=4285
Rationale
Providing information fosters cooperation,
understanding and participation in care
Organization
facilitates
accurate
skill
performance
To maintain privacy
To prevent the spread of infection
Fig16 Setting the kidney tray up with face towel covered mackintosh
21
Care Action
10. Instruct the client to brush teeth
Points of instruction
1) Client places a soft toothbrush at a 45 angle to
the teeth.
2) Client brushes in direction of the tips of the
bristles under the gum line with tooth paste.
Rotate the bristles using vibrating or jiggling
motion until all outer and inner surfaces of the
teeth and gums are clean.
3) Client brushes biting surfaces of the teeth
4) Client clean tongue from inner to outer and avoid
posterior direction.
11. If the client cannot tolerate toothbrush (or
cannot be available toothbrush), form swabs or
cotton balls can be used
12. Rinse oral cavity
1) Ask the client to rinse with fresh water and void
contents into the kidney tray.
2) Advise him/her not to swallow water. If needed,
suction equipment is used to remove any excess.
13. Ask the client to wipe mouth and around it.
14. Confirm the condition of clients teeth, gums and
tongue. Apply lubricant to lips.
15. Rinse and dry tooth brush thoroughly. Return
the proper place for personal belongings after
drying up.
16. Replace all instruments
17. Discard dirt properly and safety
18. Remove gloves and wash your hands
19. Document the care and sign on the records.
Rationale
Effective in dislodging debris and dental plaque
from teeth and gingival margin
22
Procedure: The procedure with cotton balls soaked sodium bicarbonate is showed here.
Care Action
1. Check clients identification and condition
Rationale
Providing nursing care for the correct client with
appropriate way.
2. Explain the purpose and procedure to the client
Providing information fosters cooperation and
understanding
3.Perform hand hygiene and wear disposable gloves To prevent the spread of infection.
4. Prepare equipments:
1) Collect all required equipments and bring the Organization
facilitates
accurate
skill
articles to the bedside.
performance
2) Prepare sodium bicarbonate solutions in gallipot. Solutions must be prepared each time before use
to maximize their efficacy
Nursing Alert
To reduce potential infection
If the client is unconscious, use plain tap water.
3) Soak the cotton ball in sodium bicarbonates Cleaning solutions aids in removing residue on
the clients teeth and softening encrusted areas.
solution(3 pinches / 2/3 water in gallipot) with
artery forceps.
4) Squeeze all cotton balls excess solution by artery To avoid inspiration of the solution
forceps and dissecting forceps and put into
another gallipot
5. Close the curtain or door to the room. Put screen. It maintains the clients privacy
6. Keep the client in a side lying or in comfortable Proper positioning prevents back strain
position.
Tilting the head downward encourages fluid to
drain out of the clients mort and it prevents
aspiration.
23
Care Action
Rationale
7. Place the mackintosh and towel on the neck to The towel and mackintosh protect the client and
chest.
bed from soakage.
8. Put the kidney tray over the towel and It facilitates drainage from the clients mouth.
mackintosh under the chin.(Fig. 18)
9. Inspect oral cavity:
1) Inspect whole the oral cavity, such as teeth, Comprehensive assessment is essential to
gums, mucosa and tongue, with the aid of
determine individual needs.
gauze-padded tongue depressor and torch.
Some clients with anemia, immunosuppression,
2) Take notes if you find any abnormalities, e.g.,
diabetes, renal impairment, epilepsy and taking
bleeding, swollen, ulcers, etc.
steroids should be paid attention to oral condition.
They may have complication in oral cavity.
10. Clean oral surfaces: (Fig.19)
1) Ask the client to open the mouth and insert the The tong depressor assists in keeping the clients
padded tong depressor gently from the angle of
mouth open. As a reflex mechanism, the client
mouth toward the back molar area. You never use
may bite your fingers.
your fingers to open the clients mouth.
2) Clean the clients teeth from incisors to molars Friction cleanses the teeth.
using up and down movements from gums to
crown.
3) Clean oral cavity from proximal to distal, outer
Friction cleanses the teeth.
to inner parts, using cotton ball for each stroke.
11. Discard used cotton ball into small kidney tray.
To prevent the spread of infection.
12. Clean tongue from inner to outer aspect.
Microorganisms collect and grow on tongue
surface and contribute to bad breath.
24
Care Action
13. Rinse oral cavity:
1) Provide tap water to gargle mouth and position
kidney tray.
2) If the client cannot gargle by him/herself,
a) rinse the areas using moistened cotton balls
or
b) insert of rubber tip of irrigating syringe into
the clients mouth and rinse gently with a small
amount of water.
3) Assist to void the contents into kidney tray. If the
client cannot spit up, especially in the case of
unconscious client, suction any solution.
14. Confirm the condition of clients teeth, gums,
mucosa and tongue.
15. Wipe mouth and around it. Apply lubricant to
lips by using foam swab or gauze piece with
artery forceps
16. Reposition the client in comfortable position.
17. Replace all equipments in proper place.
18. Discard dirt properly and safety
19. Remove gloves and perform hand hygiene
20. Document the care and sign on the records.
Rationale
To remove debris and make refresh
Rinsing or suctioning removes cleaning solution
and debris.
Solution that is forcefully irrigated may cause
aspiration
To avoid aspiration of the solution
To assess the efficacy of oral care and determine
any abnormalities
Lubricant prevents lips from drying and cracking.
Nursing Alert
Oral care for the unconscious clients
1. Special precautions while the procedure
The client should be positioned in the lateral position with the head turned toward the side.
( Rationale: It can not only provide for drainage but also prevent accidental aspiration.)
Suction apparatus is required. ( Rationale: It prevents aspiration.)
To use plain water for cleaning of
oral cavity of unconscious clients may be
advisable.( Rationale:
Potential infection may be reduced by using plain water when
the solution flows into the respiratory tract by accident.)
2. Frequency of care
Oral care should be performed at least every four hours. ( Rationale: Four hourly care will reduce the
potential
for
infection
from
microorganisms.
by
http://www.heris.nhs.uk/RMCNP/contant/mars32.htm The Royal Marsden Hospital Manual of
Clinical Nursing Procedures 6th edition.)
25
Purpose:
1.
2.
3.
4.
5.
6.
Equipments required:
1. Basin (2): for without soap (1)
for with soap (1)
2. Bucket (2): for clean hot water (1)
for waste (1)
3. Jug (1)
4. Soap with soap dish (1)
5. Sponge cloth (2): for wash with soap (1)
for rinse (1)
6. Face towel (1)
7. Bath towel (2) : for covering over mackintosh (1)
for covering over clients body (1)
8. Gauze piece (2-3)
9. Mackintosh (1)
10. Trolley (1)
11. Thermometer (1)
12. Old newspaper
13. Paper bag(2): for clean gauze (1)
for waste (1)
26
Rationale
27
Care Action
13. Upper extremities:
A to under
1) Move the mackintosh and big towel
the clients far arm.
2) Uncover the far arm.
3) Fold the sponge cloth and moisten.
4) Wash the far arm with soap and rinse. Use long
strokes: wrist to elbow elbow to shoulder
axilla hand
5) Dry by face towel
A to under
6) Move the mackintosh and big towel
the near arm and uncover it
7) Wash, rise, and dry the near arm as same as
procedure 4).
14. Chest and abdomen:
A to
1) Move the mackintosh and bath towel
under the upper trunk
B to over the chest
2) Put another bath towel
3) Fold the sponge towel and moisten
4) Wash breasts with soap and rinse. Dry by the big
towel covering.
B covering the chest to
5) Move the bath towel
abdomen.
6)Fold the sponge cloth and moisten.
7) Wash abdomen with soap, rinse and dry
8) Cover the trunk with top sheet and remove the
B from the abdomen.
bath towel
15. Exchange the warm water.
Rationale
To prevent sheet from making wet
A prevent sheet
Mackintosh and bath towel
from wetting
B provides warmth and privacy
Bath towel
Care Action
Action
18.Back and buttocks:
Skin breakdown usually occurs over bony
A under
1) Move the mackintosh and big towel
prominences. Carefully observe the sacral area
the trunk.
and back for any indications.
B.
2) Cover the back with big towel
3) Fold the towel and moisten. Uncover the back.
B.
4) Wash with soap and rinse. Dry with big towel
5) Back rub if needed
See our nursing manual Back Care
A
6) Remove the mackintosh and big towel
19. Return the client to the supine position.
To make sustainable position for perineal care
20. Perineal care:
Clean the perineal area to prevent skin irritation
See our nursing manual Perineal care
and breakdown and to decrease the potential
odor.
21. Assist the client to wear clean cloth.
To provide for warmth and comfort
22. After bed bath:
1) Make the bed tidy and keep the client in These measures provide for comfort and safety
comfortable position.
2) Check the IV flow and maintain it with the speed To confirm IV system is going properly and safely
prescribed if the client is given IV.
23. Document on the chart with your signature and Documentation provides coordination of care
report any findings to senior staff.
Giving
signature
maintains
professional
accountability
29
Purpose:
1. To improve circulation to the back
2. To refresh the mode and feeling
3. To relieve from fatigue, pain and stress
4. To induce sleep
Equipments required:
1.
2.
3.
4.
5.
6.
30
Procedure:
Care Action
1. Perform hand hygiene
2. Assemble all equipments required.
Rationale
To prevent spread of infection
Organization
facilitates
accurate
performance
To assess sufficient condition on the client
Providing information fosters cooperation
skill
31
Purpose:
1. To maintain personal hygiene of the client
2. To increase circulation to the scalp and hair and promote growing of hair
3. To make him/her feel refreshed
Equipments required:
1. Mackintosh(2): to prevent wet (1)
to make Kelly pad (1)
2. Big towel(2): to cover mackintosh (1)
to round the neck (1)
3. Middle towel (1)
4. Shampoo or soap (1)
5. Hair oil (1): if necessary
6. Brush, comb: (1)
7. Paper bag (2): for clean (1)
for dirty (1)
8. Cotton boll with oil or non-refined cotton
9. Bucket (2): for hot water
(1)
for wasted water (1)
10. Plastic jug (1)
11. Clothpin or clips (2)
12. Steel Tray (1)
13. Kidney tray (1)
14. Cushion or pillow (1)
15. Clean cloth if necessary
16. Old newspaper
17. Trolley (1)
32
Procedure:
Care Action
Rationale
33
Care Action
Rationale
34
Purpose:
1. To keep nails clean
2. To make neatness
3. To prevent the clients skin from scratching
4. To avoid infection caused by dirty nail
Equipments required:
1. Nail Cutter (1)
2. Gallipot with water (1): for cotton
3. Kidney tray (1)
4. Sponge cloth (1)
5. Middle towel (1)
6. Mackintosh (1)
7. Plastic bowl in small size (1)
8. Soap with soap dish (1)
35
Purpose:
1. To keep cleanliness and prevent from infection in perineal area
2. To make him/her comfortable
Equipments required:
1. Gloves( non- sterile) (1 pair)
2. Sponge cloth (1)
3. Basin with warm water (1)
4. Waterproof pad or gauze
5. Towels (1)
6. Mackintosh (1)
7. Soap with soap dish (1)
8. Toilet paper
9. Bed pan (1): as required
37
Care Action
Female client: (Fig.21)
Use a separate portion of the sponge towel for
each stroke
Change sponge towel as necessary.
Separate the labia and cleanse downward from
the pubic to anal area.
Wash between the labia including the urethral
meatus and vaginal area.
Rinse well and pat dry.
Male Client: (Fig.22)
Gently grasp the clients penis.
Cleanse in a circular motion moving from the
tip of the penis backwards toward the pubic area
In an uncircumcised male, carefully retract the
foreskin prior to washing the penis.
Return the foreskin to its former position.
Wash, rinse, and dry the scrotum carefully.
8. Assist the client to turn on the side. Separate the
client's buttocks and use toilet paper, if necessary,
to remove fecal materials.
9.Cleanse the anal area, rinse thoroughly, and dry
with a towel. Change sponge towel as necessary.
10.Apply skin care products to the area according
to need or doctor's order.
11. Return the client to a comfortable position.
12. Remove gloves and perform hand hygiene.
13. Document the procedure, describing the client's
skin condition. Sign the chart.
Rationale
professional
Purpose:
1. To assess the clients condition
2. To determine the baseline values for future comparisons
3. To detect changes and abnormalities in the condition of the client
Equipments required:
1.
2.
3.
4.
5.
6.
7.
39
Fig.24
Stethoscope
A stethoscope consists of : ear pieces, tubing, two heads such as the bell and the diaphragm.
Purpose:
1.
2.
3.
4.
Procedure:
Care Action
1. Wash your hands.
2. Prepare all required equipments
3. Check the clients identification.
4. Explain the purpose and the procedure to the
client.
5. Close doors and/or use a screen.
6. Take the thermometer and wipe it with cotton
swab from bulb towards the tube.
7.Shake the thermometer with strong wrist
movements until the mercury line falls to at least
95 (35 ).
8. Assist the client to a supine or sitting position.
Rationale
Handwashing prevents the spread of infection
Organization
facilitates
accurate
skill
performance.
To confirm the necessity
Providing information fasters cooperation and
understanding
Maintains clients privacy and minimize
embarrassment.
Wipe from the area where few organisms are
present to the area where more organisms are
present to limit spread of infection
Lower the mercury level within the stem so
that it is less than the clients potential body
temperature
To provide easy access to axilla.
41
Care Action
14.Remove and read the level of mercury of
thermometer at eye level.
15. Shake mercury down carefully and wipe the
thermometer from the stem to bulb with spirit
swab.
16. Explain the result and instruct him/her if he/she
has fever or hypothermia.
17. Dispose of the equipment properly. Wash your
hands.
18. Replace all equipments in proper place.
19. Record in the clients chart and give signature
on the chart.
Rationale
To ensure an accurate reading
To prevent the spread of infection
42
Procedure:
Care Action
1. Wash hands.
2. Prepare all equipments required on tray.
3. Check the clients identification
4. Explain the procedure and purpose to the client.
Rationale
Handwashing prevents the spread of infection
Organization facilitates accurate skill problems
To confirm the necessity
Providing information fosters cooperation and
understanding
To provide easy access to pulse sites
Relaxed position of forearm and slight flexion of
wrist promotes exposure of artery to palpation
without restriction.
Fig. 31
Care Action 5. 2) 6.
Fig. 30 5.1) 6.
Placing the clients forearm straight of across upper
abdomen and putting the fingertips over the radial
pulse
Fig. 31
5.2) 6.
44
c. Counting Respiration
Definition: Monitoring the involuntary process of inspiration and expiration in a patient
Purposes:
1. To determine number of respiration occurring per minute
2. To gather information about rhythm and depth
3. To assess response of patient to any related therapy/ medication
Procedure:
Care Action
1. Close the door and/or use screen.
2. Make the client's position comfortable, preferably
sitting or lying with the head of the elevated 45 to
60 degrees.
3. Prepare count respirations by keeping your
fingertips on the clients pulse.
4. Counting respiration:
1) Observe the rise and fall of the clients (one
inspiration and one expiration).
2) Count respirations for one full minute.
Rationale
To maintain privacy
To ensure clear view of chest wall and abdominal
movements. If necessary, move the bed linen.
A client who knows are counting respirations may
not breathe naturally.
45
Rationale
Handwashing prevents the spread of infection
Organization facilitates performance of the skill.
Cleansing the stethoscope prevents spread of
infection.
Providing information fosters the clients
cooperation and understanding.
Allow the client to relax and helps to avoid falsely
elevate readings.
To avoid misreading of the clients blood pressure
and find any changes his/her blood pressure from
the usual
6. Identify factors likely to interfere which accuracy Exercise and smoking can cause false elevations
of blood pressure measurement : exercise, coffee
in blood pressure.
and smoking
7. Setting the position:
1) Assist the client to a comfortable position. Be sure The client's perceptions that the physical or
room is warm, quiet and relaxing.
interpersonal environment is stressful affect the
blood pressure measurement.
2) Support the selected arm. Turn the palm Ideally, the arm is at heart level for accurate
upward. (Fig. 32 )
measurement. Rotate the arm so the brachial
pulse is easily accessible.
3) Remove any constrictive clothing.
Not constricted by clothing is allowed to access
the brachial pulse easily and measure accurately.
Do not use an arm where circulation is
compromised in any way.
46
Care Action
Rationale
8. Checking brachial artery and wrapping the cuff:
1) Palpate brachial artery.
2) Center the cuffs bladder approximately 2.5 cm
Center the bladder to ensure even cuff inflation
(1 inch) above the site where you palpated the
over the brachial artery
brachial pulse
3) Wrap the cuff snugly around the clients arm and Loose-fitting cuff causes false high readings.
secure the end approximately(Fig. 33)
Appropriate way to wrap is that you can put only
2 fingers between the arm and cuff. (Fig. 33)
4) Check the manometer whether if it is at level Improper height can alter perception of reading.
with the clients heart (Fig. 34 ).
Care Action
9.Meausre blood pressure by two step method:
(A) Palpatory method
1) Palpate brachial pulse distal to the cuff with
fingertips of nondominant hand.
2) Close the screw clamp on the bulb.
3) Inflate the cuff while still checking the pulse with
other hand. (Fig. 35 )
4) Observe the point where pulse is not longer
palpable.
5) Inflate cuff to pressure 20-30 mmHg above point
at which pulse disappears.
6) Open the screw clamp, deflate the cuff fully and
wait 30 seconds.
(B) Auscultation
1) Position the stethoscopes earpieces comfortably
in your ears( turn tips slightly forward). Be sure
sounds are clear, not muffled.
2) Place the diaphragm over the clients brachial
artery. Do not allow chestpiece to touch cuff or
clothing. (Fig. 36 )
Rationale
Palpation identifies the approximate systolic
reading. Estimating prevents false low readings,
which may result in the presence of an auscultory
gap.
47
Care Action
9. (B)
3) Close the screw clamp on the bulb and inflate the
cuff to a pressure30 mmHg above the point
where the pulse had disappeared
4) Open the clamp and allow the aneroid dial to fall
at rate of 2 to 3 mmHg per second.
5) Note the point on the dial when first clear sound
is heard. The sound will slowly increase in
intensity.
6) Continue deflating the cuff and note the point
where the sound disappears. Listen for 10 to 20
mmHg after the last sound.
7) Release any remaining air quickly in the cuff and
remove it.
8) If you must recheck the reading for any reason,
allow a 1 minute interval before taking blood
pressure again.
Rationale
Ensure that the
underestimated.
systolic
reading
is
not
48
Purpose:
1. To collect objective data from the client
2. To detect the abnormalities with systematic technique early
3. To diagnose diseases
4. To determine the status of present health in health check-up and refer the client for consultation if
needed
4. Auscultation
Auscultation means listening the sounds transmitted by a stethoscope which is used to listen to the heart ,
lungs and bowel sounds.
Equipments required:
1. Tray (1)
2. Watch with a seconds hand (1)
3. Height scale (1)
4. Weight scale (1)
5. Thermometer (1)
6.. Stethoscope (1)
7. Sphygmomanometer (1)
8. Measuring tape (1)
9. Scale (1)
10.Tourch light or penlight (1)
11. Spatula (1)
12 Reflex hammer (1)
13. Otoscope if available (1 set)
14. Disposable gloves (1 pair)
15. Cotton swabs and cotton gauze pad
16. Examination table
17. Record form
18. Ballpoint pen, pencils
Procedure:
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Action (Rationale)
Normal findings
Observe the clients ability to see, The client can hear even
hear, smell and distinguish tactile
though the speaker turns
sensations.
away.
He/she can identify objects or
reads a clock in the room and
distinguish between sharp
and soft objects.
Observe signs of distress( Alert the
examiner to immediate concerns. If
you note distress, the client may
require healthcare interventions
before you continue the exam. )
51
Abnormal findings/
Changes from normal
Client has lowered LOC and
shows irritability, short
attention span, or dulled
perceptions.
He/she is uncooperative or
unable to follow simple
commands or answer simple
questions.
At a lowered LOC, he/she
may respond to physical
stimuli only. The lowest
extreme is coma, when the
eyes are closed and the client
fails to respond to verbal or
physical stimuli, when no
voluntary movement.
If LOC is between full
awareness
and
coma,
objectively note the clients
eye movement: voluntary,
withdrawal to stimuli or
withdrawal
to
noxious
stimuli( pain) only.
Dysphasia
Dysarthria
Memory loss
Disorientation
Hallucinations
not clear/ not smooth/
inappropriate contents
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Observe facial expression and mood
Eyes are alert and in contact Eyes are closed or averted.
( These could be effected by
with you.
disease or ill condition)
The client is relaxed, smiles or The client is frowning or
frowns appropriately and has
grimacing.
a calm demeanor.
He/she is unable to answer
questions
Observe general appearance: posture, Posture is upright
Posture is stopped or twisted.
gait, and movement( To identify Gait is smooth and equal for Limbs
movements
are
obvious changes)
the
clients
age
and
uneven or unilateral.
development.
Limb
movements are bilateral.
Observe grooming, personal hygiene, Clothing reflects gender, age, He/she
wears
unusual
and dress( Personal appearance
climate.
clothing for gender, age, or
can indicate self-comfort. Grooming Hair, skin , and clothing are
climate.
suggests his/her ability to perform
clean, well-groomed,
and Hair is poor groomed, lack of
self-care.)
appropriate for the occasion.
cleanliness
Excessive oil is on the skin.
Body odor is present.
Measurement
>140(or 145)cm in female
Height
1) Ask the client to remove shoes and
stand with his/her back and heels
touching the wall.
2) Place a pencil flat on his/her head
so that it makes a mark on the
wall.
3) This shows his/her height
measured with cm tape from the
floor to the mark on the wall(or if
available, measure the height with
measuring scale)
52
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Weight
Body Mass index (;BMI) is used to assess the status of nutrition
Weigh him/her without shoes and much using weight and height in the world.
clothing.
Formula for BMI = weight(kg)/ height (m) 2
Table 2
BMI
In Adults
anorexia
underweight
in normal range
marginally overweight
overweight
obese
severely obese
morbidity obese
super obese
Take vital signs( Vital signs provide
baseline data)
36-37
Temperature
Pulse(rate/minute)
Tale the pulse rate and check the beats
Women
< 17.5
< 19.1
< 20.7
19.1-25.8
20.7-26.4
25.8-27.3
26.4-27.8
27.3-32.3
27.8-31.1
> 32.3
> 31.1
35-40
40-50
50-60
hypothermia
pyrexia
hyperpyrexia
rate/minute in adult
60-80 / min.
regular and steady
Men
< 35
38-40
> 40.1
Respiration
Count the breaths without giving notice Breaths /minute 16-20/ min. Breaths /minute
bradypnea <10/ min.
clear sound of breaths
tachypnea >20/min.
regular and steady
Biots
Cheyne-Stokes
Kussmauls (Fig.37 -41)
wheeze, stridor
Fig.37
Bradypnea
Fig. 40 Cheyne-Stokes
Fig. 38 Tachypnea
Fig. 39 Biots
Fig. 41 Kussmauls
(from Caroline Bunker Rosdabl, p.509)
53
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Hypotension: In normal adults < 95/60
Blood pressure
Take blood pressure under quiet and Hypertension
Table 3 WHO/ ISH classification of Hypertension(1999)
warm room.
Classification
SBP(mmHg)
DBP(mmHg)
<120
<80
Normal
Pre-hypertension
120-139
80-89
Grade 1
140-159
90-99
Grade 2
160-179
100-109
>/= 180
>/= 110
Grade 3
SBP: Systolic Blood Pressure, DBP: Diastolic Blood pressure
B. Skin Assessment
Assess integumentary structures(skin,
hair, nails) and function
Skin
Inspection and palpation
The color varying from
1) Inspect the back and palms of the
black brown or fair
clients hands for skin color. Compare
depending upon the
the right and left sides. Make a similar
genetic factors
inspection of the feet and toes, Color variations on dark
comparing the right and left sides. (
pigmented skin may be
Extremities
indicate
peripheral
best seen in the mucous
cardiovascular function)
membranes, nail beds,
sclera, or lips.
1) Palpate the skin on the back and
palms of the clients hands for
moisture, texture.
a. moisture
slight moist, no excessive
b. texture
moisture or dryness
firm, smooth, soft, elastic
skin
erythema
loss of pigmentation
cyanosis
pallor
jaundice
54
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Depression recovers slowly or
remains. Edema indicates
fluid retention, a sign of
circulatory disorders.
Nail
1) Inspect and palpate the fingernails Pink color
and toenails. Note color, shape and Logitadional bands of pigment
any lesions.
may be seen in the nails of
normal people.
Erythema
Eccymosis
Lesions includes rashes,
macules, papules, vesicles,
wheals, nodules, pustules,
tumors, or ulcers.
Wounds include incisions,
abrasions,
lacerations,
pressure ulcers.
2) Check capillary refill by pressing Normally color return is Cyanosis nail beds or
instant(<3 seconds)
the nail edge to blanch and then
sluggish
color
return
release pressure quickly, noting the Nails
should
have
no
consider cardiovascular or
return of color.
discoloration, ridges, pitting,
respiratory dysfunction.
thickening, or separation from
the edge.
Hair and scalp
1) Inspect the hair for color, texture, Color may vary from pale Hair is excessively dry or oily
growth, distribution
blonde to total black.
Excessive hair loss( alopecia)
Texture varies fine to coarse
or
coarse
hair
in
and looks straight to curly.
hypothyroidism
fine
silky
hair
in
hyperthyroidism
pediculosis
dandruff
55
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
2) Inspect the scaly, lumps, nevi, or All area should be clean and redness and scaling in
other lesions.
free of any lesions, scaly,
seborrheic dermatitis
lumps, and nevi.
psoriasis
C. Head and Neck Assessment
Assess central neurologic function,
vision, hearing, and mouth
structures.
Skull
1) Observe for the size, shape, and Head is symmetrical, round, Enlarged
skull
in
symmetry.
and erect in the midline.
hydrocephalus,
Pagets
2) Palpate and note any deformities,
diseases of bone.
depressions, lumps, or tenderness.
Redness after trauma
Face
Inspect the clients facial expression, relaxed facial expression
Moon face with red cheeks in
asymmetry, involuntary movements, He/she
doesnt
have
Cushings syndrome
edema, and masses
involuntary movement
Edematous face around the
eyes (in the morning ) and
pale in nephritic syndrome
Decreased facial mobility
and blunt expression in
Parkinsons disease
Eyes
1) Position and alimentation:
and
outward
Stand in front of the client and No deviation and abnormal Inward
profusion
deviation
inspect the both eyes for position
Abnormal profusion in
a n d
a l i g n m e n t .
disease or ocular tumors
2) Eyebrows:
Inspect the eyebrows , noting their
Scaliness
in
seborrheic
quantity and distribution and any
dermatitis
Lateral
sparseness
in
scaliness
hypothyroidism
3) Eyelids:
Inspect the position, presence of
Ptosis
edema, lesions, condition and
Entropian
Ectropion
direction of the eyelashes, and
Lid riraction
adequacy with eyelids doze.
Chalazion
Sty
Dacryocystitis
Red inflamed lid margin
Inwards direction
Failure of the eyelids to close
exposes the corneas to
serious damage
56
Action (Rationale)
Normal findings
4) Lacrimal apparatus
Inspect the region of the lacrimal No lumps and
gland and lacrimal sac for swelling.
around the eyes
Abnormal findings/
Changes from normal
Fig. 44 Conjunctiviis
(from Carolyn Jarvis, p.335)
Fig.43
Transparent, no
and white spots
7) Pupils
( Pupillary size, shape, and Pupils are equal, round, and Pupils are unequal.
accomonation indicate the status
symmetry.
Miosis refers to constriction
od intracranial pressure)
of the pupils
Inspect the size, shapes and
Mydriasis to dilation
compare symmetry. If the pupils
are larger(>5 mm), small(<3 mm) or
unequal, measure them.
57
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Poor
convergence
hypothyroism
in
Myopia(near-sightedness)
Hyperopia(far-sightedness)
is impaired in middle and
elder people.
Legal blindness
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Ears
Inspect and palpate the external ears.
1) Inspect location of ears
The top of the pinnae meet or The top of the pinnae dont
meet or cross the eye
crosses the eye-occiput line
occiput line.
(imaginary line drawn from
the outer canthus of the ear to
the occipital protuberance)
2) Inspect the shape and measure the
size.
3) Tenderness
Move the pinna and push on the
tragus
Palpate the mastoid process
59
Action (Rationale)
5) Voice test
( Whispered is a high frequency
sound and is used to detect high
tone loss)
Test one ear at a time.
Stay 30-60 cm from clients ear.
Exhale and whisper slowly some
two syllable words (such as
Tuesday, Baseball and fourteen.)
Nose
1) Inspect the anterior and inferior
surface of the nose.
Give gentle pressure in the tip
of the nose with your thumb to
widen the nostrils
with the aid of penlight, you can
get a partial view of each nasal
vestibule.
Observe symmetry, deformity,
size, and flaring.
If indicated by pressing on
each ala nasi in turn and ask the
client to breath in.
(To test for nasal obstruction)
Normal findings
Abnormal findings/
Changes from normal
No pain
Symmetry in size
Asymmetrical in size
Flaring nostrils
both Obstruction
in
vestibule by polyp.
60
right
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Polyps are pale translucent
masses that usually come
from the middle meatus
Ulcers may result from nasal
use of cocaine
Mouth
If the client wears dentures, offer a
piece of paper towel and ask to
remove it so that you can see the
mucosa underneath.
1) Lips
Observe the color, moisture
Pink, moist and intact skin
Lips bluish(: cyanosis) and
61
Aphthous ulcer
Yelloish spots
Kopliks spots
Small red spots(: petechiae)
Thickened white patch( :
Leuloplakia)
Redness of gingivitis
Black line of lead poisoning
Swollen interdental papillae
in gingivitis
Ulcerative gingivitis
Gums enlargements
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Missing or looseness of teeth
Dental caries
Attrition of teeth
Erosion of teeth
Abrasion of teeth with
notching
Inspect the color of roof of the No lesions, white plaque and Thrush on the palpate(:
thick, white plaques)
extra bony growth
mouth and architecture of the
Kaposis sarcoma(: deep
harelip.
purple color of lesions) in
AIDs
Torus palatinus (: midline
bony growth in the hard
palate)
3) Tongue and floor of the mouth
Hairy tongue
Inspect the tongue for color, texture Pink, moist and papillae
Midline fissure presents and Fissured tongue
of dorsum, papillae symmetry
Smooth tongue
be symmetrical.
Whitening coating tongue
Red or pale, dry papillae
fissure absent
Asymmetric
protrusion
suggests a lesion of cranial
nerve XII
4) Inspect the sides and undersurface No whit or reddened areas
of the tongue and the floor of the No nodules or ulcerations
mouth.
Pharynx
1)Ask the client to open the mouth
and say ah. This actions help to
see the pharynx well. If not press
the tongue, press spatula firmly
down upon the midpoint of the
arched tongue.
2) Inspect soft palate anterior and
posterior pillars, uvula, tonsils, and
pharynx( To detect color,
symmetry, presence of exudates,
swelling, ulceration or tonsillar
enlargement, and tenderness.)
Pink throat
Exudative tonsillitis(: red
Pink and small tonsils
and enlarged tonsils)
No swelling, exudates, and Throat with white exudates
ulceration
Redness and varcularity of
No difficulty in swallowing
the pillars and uvula in
pharyngitis
62
Action (Rationale)
Normal findings
Neck
1) Inspect the neck
(Head lift occurs with muscle
(To detect its symmetry and any
spasm.)
Head
positions
masses or scars, enlargment of the
centered in the midline and
parotid or submandibular glands,
the head should be held erect
and condition of any visible lymph Lymph nodes are neither
nodes)
visible or redness
Abnormal findings/
Changes from normal
Throat is dull red and gray
exudates is present in uvula,
pharynx and tongue, which
cause airway obstruction
Difficulty in swallowing
In CN X paralysis, the soft
palate fails to rise and the
uvula deviates to the
opposite site.
Rigid head and neck occurs
with arthritis
Scar at thyroid site
Enlargement of lymph nodes
Redness of lymph nodes
Preauricular
Posterior auricular
Occipital
Jugulodigstric
Submandibular
Superficial cervical
Submental
Posterior cervical
Deep cervical chain
Supraclavicular
Fig. 49 Lymph nodes (from Carolyne Jarvis, p. 281)
63
Action (Rationale)
Normal findings
Lymph nodes
1)Palpate the lymph nodes by using Cervical nodes often are
the pads of your index and middle
palpate in healthy person,
fingers
although this palpability
2)Move the underlying tissues in each
decrease with age
area
Normal nodes feel movable,
3)Examine both sides at once
discrete, soft, non-tender
4)Feel in sequence for the following
nodes: (Fig. 49)
preauicular
posturiaduricular
occipital
tonsillar
submandibular
submental
superficial cervical
posterior cervical
deep cervical chain
supracravicular
(To detect any palpable nodes with
location, size, shape, delimitation,
mobility,
consistency,
and
tenderness.)
Trachea
1) Inspect the trachea (To detect
any deviation from its usual
midline position)
2) Palpate for any trachea shift. Place
your index finger on the trachea in
the sternal notch and slip it off to
each side( To detect any
abnormalities)
Thyroid gland
1) Inspect thyroid gland:
Ask the client to sip some water,
to extend the neck, and swallow.
Observe for upward movement
of the thyroid gland, noting its
contour and symmetry.
You must confirm that thyroid
gland rise with swallowing and
then fall to their resting position.
Abnormal findings/
Changes from normal
Parotid is swollen with
mumps
Tender
nodes
suggest
inflammation
Hard or fixed nodes suggest
malignancy
Lymphadenopathy
is
enlargement of the lymph
nodes( > 1 cm) due to
infection,
allergy
or
neoplasm
Enlargement
of
a
supraclavicular
node,
especially on the left,
suggests possible metastasis
from a thorax or an
abdominal malignancy
Diffuse
lymphadenopathy
raises the suspicious of
HIV/AIDs
64
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Diffuse enlargement in
endemic goiter
Soft in Graves disease
Firm in malignancy
Tenderness in thyroiditis
Multinodular
goiter
is
additional risk factors for
malignancy
65
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Inspection
Shoulders are even; scapulae Structural deformities or
Stand behind the client and observe
asymmetry are present:
are at the same level; spine is
the posterior chest for shape and
movement. (To identify shape or
Scoliosis(:lateral curvature)
midline and straight.
Lordosis(:
pronounced
movement;
assess
respiratory Posterior chest slightly rises
lumbar curvature)
and falls on respiration.
movement)
Kyphosis(: abnormal spinal
curvature and vertebral
rotation deform the chest)
66
Barrel thorax
Funnel breast
Pigeon breast
Scoliosis
Kyphosis
Fig. 52
Abnoramal thorax
67
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
68
Action (Rationale)
Fig.53
Normal findings
Abnormal findings/
Changes from normal
Percussion
Lung Fields
Percuss the posterior chest Resonance is normal lung Dullness replaces resonance
comparing both sides.( To
sound: except heart area
when fluid or solid tissue
identify and locate any area
because
heart
normally
replaces air containing lung or
with
an
abnormal
produces dullness bound, liver
accupies the pleural space, i.g.,
percussion).( To enhance
produces dullness stomach
pneumonia, pleural effusion,
percussion) (Fig. 55 )
produces tympany, muscles and
atelectasis, or tumor.
1) Percuss the posterior chest
bone produces flat
Hyperresonance is found in
from the apices and then to
COPD and asthma
interspaces with a -5 cm
Hyperresonant or tympanitic in
intervals.
pneumothorax
2) Note any abnormal findings
Diaphragm excursion
(To map out the lower lung The diaphragm excursion An abnormal high level of
border, both in expiration and
should be equal bilaterally and
dullness or absence of excursion
inspiration ) (Fig. 56)
measure about 3 to 5 cm in
occurs with pleural effusion or
1) Ask the client to exhale and
adults
atelectasis of the lower lobes
hold it briefly while you percuss
down the scapular line
69
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
70
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Auscultation
1)Listen
to
the
breath Breath sounds are usually Decreased or abscent breath
posteriorilly with mouth open
louder in upper anterior lung
sounds occur i.g., atelectasis,
and more deeply than the
fields
pleural
effusion,
normal ( To note intensity, Bronchial,
bronchovesicular,
pneumothorax,
chironic
identify any variation and any
vesicular sounds are normal
obstructd pulmonary disease(;
adventitious sounds)
breath sounds
COPD)
2) Repeat auscultation in the None adventitious sounds
Increased breath sounds occur
posterior chest.
when
consolidation
or
compression yields a dense
lung area, i.g., pneumonia,
fluid in the intrapleural space
71
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
(Refer to the posterior chest)
Lungs
with
chronic
emphysema
result
in
hyperresonnance
Auscultation
1) Auscultate the lungs fields over
the anterior chest from the
apices in the supraclavicular
areas down to the 6th rib
2) Progress from side to side and
listen to one full respiration in
each location
3) Evaluate normal breath
sounds and note abnormal
breath sounds
72
73
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
E. Heart/ Precordium
For most of the cardiac
examination, the client should be
supine with the head elevated
30. Two other position are also
needed, a. turning to the left side,
b. leaning forward. the examiner
should stand at the
clients
right.
Inspection
.
Inspect the anterior chest for It is easier to see in children A heave or lift is a sustained
pulsation, you may or may not
and in those with thinner chest
forceful thrusting of the
see the apical impulse.
ventricle during systole. it
occurs
with
ventricular
hypertrophy;
A
right
ventricular heave is seen at the
sternal border. A left ventricular
heave is seen at the apex
Palpate the Apical impulse
( To detect some abnormal
conditions)
1) Localize the apical impulse by
using one finger pad
2) Asking the client to exhale
and then hold it aids the
examiner in locating the
pulsation.
3) Ask the client to roll midway to
the left to find
4) Note location, size, amplitude,
and duration
Cardiac enlargement:
Left ventricular dilatation
displaces impulse down and to
left , and increases size more
than one space
Increased fore and duration
occurs with left ventricular
hypertrophy
Not palpable with pulmonary
emphysema due to overriding
lungs
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
A thrill is a palpable vibration.
The thrill signifies turbulent
blood flow and accompanies
loud murmurs
Percussion
(To outline the hearts borders The left border of cardiac Cardiac enlargement is due to
and detect heart enlargement)
dullness is at the midclavicular
increased ventrivular volumeor
1) Place your stationary finger in
line in the fifth interspace, and
wall thickness: it occurs with
the clients fifth intercostals
by the second interspace the
hypertension, heart failure and
space over on the left side of the
border of dullness concides with
cardiomyopathy
chest near the anterior axillary
the left sternal border.
line
The right border of dullness
2) Slide your stationary finger
matches the sternal border
toward yourself, percussing as Percussion sounds doesnt
you go
enlarge
3) Note the change of sound from
resonance over the lung to
dull( over the heart)
Auscultation
Identify the auscultatory areas
where you listen. These include
the four traditional valve areas.
They are:
Second right interspace aortic
valve area
Second
left
interspacepulmonic valve area
Leftlower
sternal
bordertricuspid valve area
Fifth interspace at around left
midclavicular line- mitral valve
area
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Count
a
serial
occurs with atrial fibrillation
measurement(one after the
and heart failure
other) of apical beat and radial
pulse
4) Identify S1 and S2
First heart sound is S1(lub) S1 is loudest at the apex
Both
heart
sounds
are
caused by closure of the AV
diminished
in
emphysema,
valves. S1 signals the beginning
obesity and pericardial fluid.
of systole
Second heart sound is S2 is loudest at the base
S2(dup) is associated with Lub-dup is the normal heart
closure of the aortic and
sound
pulmonic valves.
5) Listen S1 and S2
Focus on systole, then S3 occurs immediately after S2 A pathologic S3 (ventricular
diastole
and S4 occurs just before S1
gallop) occurs until heart failure
Listen for any extra heart
A pathologic S4 (atrial gallop)
sounds to note its timing and
occurs with CAD
characteristics
6) Listen for murmurs
If you hear a murmur, describe Some clients may
it
by
indicating
these
innocent murmurs
characteristics:
timing,
loudness(Grade i- vi), pitch,
pattern,
quality,
location.
radiation, and posture
76
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Symmetry
or
a
slight A sudden increase in the size of
asymmetry in size
one
breast
signifies
Often the left breast is slightly
inflammation or new growth
larger than the right
Skin
Inspect color, textile, bulging, The skin normally is smooth
dimpling, any skin lesions or
and of even color
edema.
A fine blue vascular network is
visible
normally
during
pregnancy
Pale linear striae, or stretch
marks, often follow pregnancy
No edema
Hyperpigmentation
Redness and heat with
inflammation
Unilateral dilated superficial
veins in a nonpregnant woman
Edema
Fig.64
Mastitis
77
Deviation in pointing
Recent
nipple
retraction
signifies acquired disease
Explore
any
discharge,
especially in the presence of a
breasts mass
Rarely, glandular tissue, a
supermumerary breast, or
polymastia is present
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Maneuvers to screen
(To inspect skin retraction signs
due to fibrosis in the breasts
tissue)
1) Direct the woman to change
position while you check the
breasts for skin retraction sings
2) First ask her to lift the arms Both breasts should move up A lag in movement of one
symmetrically
breast
slowly over the head
3) Next ask her to push her A slight lifting of both breast A dimpling or a pucker(, which
will occur
indicates skin retraction)
hands onto her hips and to
push her two palms together
breast
show
the Fixation to chest wall or skin
4) Ask the woman with large Both
symmetric
free-forward
retraction
pendulous breasts to lean
movement
forward while you support her
forearms
Inspect and palpate the axillae
1) Ask the woman to have sitting Usually nodes are not palpable Nodes enlarge with any local
Any enlarged and tender lymph
infection of the breast, arm, or
position
nodes
hand, and with breast cancer
2) Inspect the skin, noting any
metastases
rash or infection
3) Lift the womans arm and
support it yourself
use your right hand to
palpate the left axilla
Reach your fingers high into
axilla
Move them firmly down in
four directions: down the chest
wall in a line from the middle of
the axxila, along the anterior
border of the axilla, along te
posterior border, and along the
inner aspect of the upper arm
Move the womans arm
through ROM to increase the
surface area you can reach
Palpate the breasts
1) Help her to a supine position
2) Tuck a small pad or towel
under the side to be palpated
and raise her arm over her
head
78
Action (Rationale)
3) Use the pads of your three
fingers and make a gentle
rotary motion on the breast
Start at the nipple and
palpate out to the periphery as
if Spokes-on- a- wheel pattern
of palpation, or
Start at the nipple and
palpate in Concentric-circles
pattern
of
palpation,
increasing out to the periphery
Move in a clockwise
direction, taking care to
examine every square inch of
the breast
If you feel a lump or mass,
note these characteristics:
Location, shape, consistency,
movable, distinctness, nipple(;
is it displaced or retracted?),
skin over the lump, tenderness,
lymphadenopahy
Normal findings
Abnormal findings/
Changes from normal
In nulliparous women, normal Heat, redness, and swelling in
breast tissue feels firm, smooth,
nonlactating
and
and elastic
nonpostpartum breasts indicate
After pregnancy, the tissue feels
inflammation
softer and looser
Premenstrual enlargement is
normal
Inflammary ridge(; a firm
transverse ridge of compresses
tissue in the lower quadrants)
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Fig. 66 Gynemastia
(from Carolyne Jarvis, p.434)
G. Abdomen
Preparation
Expose the abdomen to be visible
fully
The client should be emptied the
bladder( To prevent discomfort)
Keep the room warm. The
stethoscope endpiece , your hands
must be warm( To avoid chilling
and tensing of muscles)
Position the client supine, with the
head on a pillow, the knees bent or
on pillow, and arms at the sides or
across the chest( To enhance
abdominal wall relaxation)
Inquire about any painful areas
and examine such an area last(To
avoid any muscle guarding)
Action (Rationale)
Normal findings
Skin
1) Inspect the skin(To detect
The surface is smooth and even,
with homogenous color
abnormalities,
i.g.,
Old silver striae or stretch
pigmentation)
marks
is
normal
after
2)Note striae, scars, lesions,
pregnancy or gained excessive
rashes, dilated veins, and
weight
turgor
Recent striae are pink or blue
Good turgor
Umbilicus
Observe its contour, location,
inflammation or bulges
Abnormal findings/
Changes from normal
Localized bulges in the
abdominal wall due to hernia
Bulging flanks of ascites,
suprapubic bulge of a distended
bladder or pregnant uterus
Lower abdominal mass of an
ovarium or uterine tumor
Asymmetry from an enlarged
organ or mass
Redness
with
localized
inflammation
Jaundice
Skin glistening, taut, and striae
in ascites
Pink-purple
striae
with
Cushings syndrome
Prominent, dilated veins of
hepatic cirrhosis or of inferior
vena caval obstruction
Lesions, rashes
Poor turgor occurs with
dehydration
Pulsation or movement
1)Observe the pulsations from Normally, aortic pulsations is Marked pulsation of the aorta
occurs with widened pulse
visible in epigastrium
the aorta beneath the skin in
pressure; i.g., hypertension,
the epigastric area
aortic
insufficiency,
thyrotoxicosis
2) Observe for peristlsis waves
Waves of peristalsis sometimes Increased peristalsis waves
with a distended abdomen
are visible in very thin persons
indicates intestinal obstruction
81
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Vascular sounds
1) Listen to the abdomen , noting Usually no such sounds is A systolic bruit(; a pulsatile
present
the presence of any vascular
blowing sound) occurs with
sounds or bruits
stenosis or occlusion of an
2) Using firmer pressure, check
artery
over the aorta, renal arteries,
iliac, and femoral arteries,
especially in person with
hypertension
3) Note location, pitch, and
timing of a vascular sound
4)Listen over the liver and spleen
Friction rubs in liver tumor or
for friction rubs
abscess, gonococcal infection
around liver , splenic infection
82
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
A: in supine position
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Muscle guarding
Mass
Tenderness
Involuntary rigidity indicates
acute peritoneal inflammation
Deep palpation
Perform deep palpation
(Fig. 70 A. B.)
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
1) Perform deep palpation using Normally palpable structure: Tenderness occurs with local
the same technique described
xiphoid process, normal liver
inflammation,
with
earlier, but push down 5 to 8
edge, right kidney, pulsatile
inflammation
of
the
cm (2 to 3 inches)
aorta, rectus muscles, sacral
peritoneum or underlying
2) Moving clockwise, explore the
promontory, cecum ascending
organ, and with an enlarged
entire abdomen
colon, sigmoid colon, uterus, full
organ whose capsule is
3) To over come the resistance of
bladder
stretched
a very large or obese abdomen, Mild tenderness is normally
use a bimanual technique
present when palpating the
The top hand does the
sigmoid colon
pushing
The bottom hand is relaxed
and can concentrate on the
sense of palpation
Liver
Liver palpable as soft hedge or
1) Stand on the clients right side Liver is not usually palpable
irregular contour
2) Place your left hand under the People may be palpable the
edge of the liver bump Except with a depressed
clients back parallel to the
immediately below the costal
diaphragm, a liver palpated
11th and 12th ribs
margin as the diaphragm
more than 1 to 2 cm below the
3)
Lift up to support the
pushes
it
down
during
right costal margin is enlarged
abdominal contents
inhalation: a smooth structure If enlarged, estimate the
4) Place your right hand on the
with a regular contour, firm
amount of enlargement beyond
RUQ, with fingers parallel to
and sharp edge
the right costal margin.
the midline(Fig. 71 )
Express it in centimeters with
5) Push deeply down and under
its consistency and tenderness
the right costal margin
6) Ask the client to take a deep
breath
7) Feel for liver sliding over the
fingers as the client inspires
8) Note any enlargement or
tenderness.
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Spleen
In supine position:
Normally spleen is not palpable The spleen must be enlarged
1) Reach your left hand over the No
enlargement
and
three times its normal size to be
abdomen and behind the left
tenderness
felt
th
th
side at the 11 and 12 ribs (Fig.
The enlarged spleen is palpable
72 A. )
about 2 cm below the left costal
2) Lift up for support
margin on deep inspiration
3) Place your right hand obliquely
on the LUQ with the fingers
pointing toward the left axilla
and just inferior to the rib
margin
4) Push your hand deeply down
and under the left costal
margin
5) Ask the client to take a deep
breath
In right lateral position:
1) Roll the client onto his/her
right side to displace the spleen
more
forward
and
downward(Fig. 72 B.)
2) Palpate as described earlier
86
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Kidneys
Palpation in the right kidney:
Both kidneys are not usually
1) Place the client in the supine
palpable
position
A normal right kidney may be
2) Place your left hand on the
palpable in well-relaxed women
client between lowest rib and No change while breathing
the pelvic bone
deeply on both sides
3) Place your right hand on the
clients side below the lowest
rib or in the RUQ. Your hands
are placed together in a
duck-bill position at the
clients right flank (Fig.73 A.)
4) Ask the client to take a deep
breath.
5) At the peak of inspiration,
press your right hand and
deeply into the RUQ, just
below the coastal margin
6) Try to capture the kidney
between two hands
7) Note the enlargement or
tenderness.
Enlarged kidney
Tenderness
Kidney mass
Causes of kidney enlargement
include hydronephrosis, cyst or
tumors
Bilateral enlargement suggests
polycystic kidney disease
B. Left kidney
87
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Rebound
tenderness
( Bulumbergs sign)
( To test rebound tenderness As a normal or negative, no Pain in release of pressure
when the client feels abdominal
pain on release of pressure
confirms rebound tenderness,
pain or when you elicit
which is a reliable sign of
tenderness during palpation )
peritoneal
inflammation.
Peritoneal
inflammation
1) Choose a site away from the
accompanies appendicitis
painful area
2) Hold your hand 90 degrees, or
perpendicular, to the abdomen
3) Push down slowly and deeply
and then lift up suddenly
(Fig. 74 A.,B.)
Action (Rationale)
Normal findings
Inguinal area
1) Lift the drape or cloth to Normally no palpable nodules
expose the inguinal area and
legs
2) Inspect and palpate each groin
for the femoral pulse and the
inguinal nodes
88
Abnormal findings/
Changes from normal
Palpable nodes
Swollen, tenderness
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Bladder
1) The bladder normally cannot Normally not palpable and Bladder distension from outlet
be examined unless it is
tenderness
obstruction
distended above the symphysis The dome of distended bladder Suprapubic tenderness in
pubis on palpation.
feels smooth and round
bladder infection
2) Check for tenderness
3) Use percussion to check for
dullness and to determine how
high the bladder rises above
the symphysis pubis
NOTE:
Table 5 Common sites of referred abdominal pain
(from Carolyne Jarvis, p.593)
89
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
H. Musculoskeletal system
Inspection the muscle and joints
1) Ask the client to stand
No bone or joint deformities
2) Inspect his/her neck , shoulder, No redness or swelling of joints
arms, hands, hips, knees, legs, No muscle wasting
ankle and feet.
3) Compare one side with other
side
4) Note the size and contour of
the joint, skin and tissues over
the joints for color, swelling,
and any masses or deformities
90
Action (Rationale)
Palpation
1) Palpate each joint, including
its skin for tenderness, its
muscles, bony articulations,
and area of joint capsule
2) Note any heat, tenderness,
swelling or masses.
3) If any tenderness occur, try to
localize it to specific anatomic
structure(skin,
muscle,
ligaments, tendons, fat pads or
joint capsule)
4) Holding the each joint one by
one, ask the client to move
these areas. note the range of
motion and for any rough
sensation at the joint
Normal findings
Abnormal findings/
Changes from normal
No swelling, tenderness or
redness in joint
Normal temperature
The
synovial
membrane
normally is not palpable
A small amount of fluids is
present in the normal joint, but
not palpable
91
vasoconstriction
Action (Rationale)
Normal findings
Palpation
1) Press the skin gently and No impression left on the skin
firmly at the arms, hands over
when pressed
the skin of the tibia, ankles and Pit edema commonly is seen if
feet for 5 seconds, and then
the person has been standing
release .
all day or during pregnancy
2) Note whether the finger leaves
an impression on the skin
indication edema
3) Ask the client to stand so that
you assess the venous system
4) Note any visible dilated and
tortuous veins
Abnormal findings/
Changes from normal
Bilateral pitting edema occurs
with heart failure, diabetic
neuropathy, or hepatic cirrhosis
Unilateral edema occurs with
occlusion of a deep vein
Uni- or bilateral edema occurs
with lymphatic obstruction
Varicosities occur
saphenous veins
in
the
Muscles strengthen
1) Push against the clients Equal strengthen is both hands Muscular weakness on one or
hands, and then feet
and feet
both hands and feet
2) Ask him/her to resist the push No muscular weakness
I. Nervous system
For sensation
1) Ask the client to close the eyes Feels pain, light touch and Decreased pain sensation or
2) Select areas on face , arms,
vibration
touch sensation
hands, legs and feet
Equally in both side of his/her Unable to feel vibration
3) Give a superficial pain, light
body
touch and vibration to each site
by turn
4) Note the clients ability of
sensation on each site
Test for Cranial nerves
Cranial nerve I: Olfactory nerve
(To test the sense of smell )
1)Ask the client to close his/her
eyes
2) Ask him/her the source of smell
using familiar, conveniently
obtainable, and non-noxious
smell such as coffee or tooth
paste
92
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Test stereognosis
1) Ask the client to close his/ her Normal client can identify the Inability to identify object
eyes
familiar object
correctly, especially in brain
2) Place a familiar object(i.g., clip,
stroke
key or coin) in the clients hand
3) Ask the client to identify it
Test for the cerebellar function of
the upper extremities
Use finger-to- nose test or Coordinated,
rapid-altering movement test
movement
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Superficial reflex
Planter reflex (L4 to S2)
1) Position the thigh in slight Normal response is planter Babinski sign: this occurs with
external rotation
flexion of all the toes and
upper motor neuron disease
2) With the reflex hammer,
inversion and flexion of the
forefoot
draw a light stroke up the
lateral side of the sole of the
foot and inward across the ball
of the foot
3) Observe the response
94
Fig. 75
Biceps reflex
95
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
J. Anus
Inspect the perineal area for any No irritation, fissure, cracks
Presence of anal irritation, anal
irritation, cracks, fissure or No enlarged blood vessels in
fissure, enlarged and blood
enlarged vessels
anus
vessels
K. Male Genitalia
Inspect and palpate the penis
1) Inspect the skin, glans, and
urethral meatus
2) If you note urethral discharge,
collect a smear for microscopic
examination and a culture
3) Palpate the shaft of penis
between your thumb and first
two fingers
Inflammation
Lesions
Presence of sore or lump
Phimosis: unable to retract the
foreskin
Edges that are red, everted,
edematous, along with purulent
discharge, suggested urethritis
Nodule
or
induration,
tenderness on the penis
L. Female genitals
For inspection of female
genitals place the client in the
supine position with the knee
flexed and feet resting on the
examination table.
External genitalia
Inspection
1)Note
skin
color,
hair Labia are of the same color and
distribution, labia majora, any
size
lesions, clitoris, labia minora, no redness or swelling in labia
urethral opening, vaginal Urethral opening appears
opening, perineum, and anus.
stellate and in midline
96
Action (Rationale)
Normal findings
Abnormal findings/
Changes from normal
Vaginal opening may appear as Bleeding
a vertical slit
Perineum is smooth
Anus has coarse skin increased
pigmentation
No usual discharge from the
vagina
No prolapse
No bleeding from the vagina
except during mensturation
97
Purpose:
1.
2.
3.
4.
5.
Equipments required:
1. Nasogastric tube in appropriate size (1)
2. Syringe 10 ml (1)
3. Lubricant
4. Cotton balls
5. Kidney tray (1)
6. Adhesive tape
7. Stethoscope (1)
8. Clamp (1)
9. Marker pen (1)
10.Steel Tray (1)
11.Disposable gloves if available (1 pair)
98
Procedure:
Care Action
1. Check the Doctors order for insertion of
Nasal-gastric tube.
2.Explain the procedure to the client.
3. Gather the equipments.
4. Assess clients abdomen
Rationale
This clarifies procedure and type of equipment
required.
Explanation facilitates client cooperation.
Organization provides accurate skill performance.
Assessment determines presence of bowel sounds
and amount of abdominal distention.
Hand hygiene deters the spread of
microorganisms. But sterile technique is not
needed because the digestive tract is not sterile.
Gloves protect from exposure to blood or body
fluids.
Upright position is more natural for swallowing
and protects against aspiration, if the client
should vomit.
Tube passes more easily through the nostril with
the largest opening.
99
Care Action
5) Advance the tube in a downward and backward
direction when the client swallow.
6) Stop when the client breathes
7) If gagging and coughing persist, check
placement of tube with a tongue depressor and
flashlight if necessary.
8) Keep advancing the tube until the marking or
the tape marking is reached.
Nursing Alert
Do not use force. Rotate the tube if it meets
resistance.
Discontinue the procedure and remove the
tube if the tube are signs of distress, such as
gasping, coughing, cyanosis, and the
inability to speak or hum.
11. While keeping one hand on the tube, verify the
tubes placement in the stomach.
a. Aspiration of a small amount of stomach
contents:
Attach the syringe to the end of the tube and
aspirate small amount of stomach contents.
Visualize aspirated contents, checking for color
and consistency.
b. Auscultation:
Inject a small amount of air( 10- 15 ml)into
the nasogastric tube while you listen with a
stethoscope approximately 3 inches ( about 8
cm) below the sternum.
c. Obtain radiograph of placement of tube( as
ordered by doctor.)
12. Secure the tube with tape to the clients nose.
Nursing Alert
Be careful not to pull the tube too tightly
against the nose.
13. Clamp the end of nasal-gastric tube while you
bend the tube by fingers not to open
14. Putt off and dispose the gloves, Perform hand
hygiene
16. Replace and properly dispose of equipment.
Rationale
17. Record the date and time, the size of the Documentation provides coordination of care
nasal-gastric tube, the amount and color of
drainage aspirated and relevant client reactions.
Sign the chart.
18. Report to the senior staff.
To provide continuity of care
100
Organization
performance
Rationale
facilitates
accurate
skill
101
Purpose:
1. To provide adequate nutrition
2. To give large amounts of fluids for therapeutic purpose
3. To provide alternative manner to some specific clients who has potential or acquired swallowing
difficulties
Equipments required:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
102
Procedure:
Care Action
Rationale
1. Assemble all equipments and supplies after Organization
facilitates
accurate
skill
checking the Dr.s prescription for tube feeding
performance
Checking the prescription confirms the type of
feeding solution, route, and prescribed delivery
time.
2. Prepare formula:
Feeding solution may settle and requires mixing
a. in the type of can:
before administration.
Shake the can thoroughly. Check expiration Outdated formula may be contaminated or have
date
lessened nutritional value.
b. in the type of powder:
Mix according to the instructions on the
package, prepare enough for 24 hours only and Formula loses its nutritional value and can
refrigerate unused formula. Label and date the
harbor microorganisms if kept over 24 hours.
container. Allow formula to reach room Cold formula cause abdominal discomfort or
temperature before using.
sometimes diarrhea.
c. in the type of liquid which prepare by hospital
or family at a time:
Make formula at a time and allow formula to
reach room temperature before using.
3. Explain the procedure to the client
Providing explanation fosters clients cooperation
and understanding
4. Perform hand hygiene and put on disposable To prevent the spread of infection
gloves if available
5. Position the client with the head of the bed This position helps avoiding aspiration of feeding
elevated at least 30 degree angle to 45 degree
solution into lungs
angle
6. Determine placement of feeding tube by:
a. Aspiration of stomach secretions
Aspiration of gastric fluid indicates that the tube
Attach the syringe to the end of feeding tube
is correctly placed in the stomach
Gently pull back on plunger
Measure amount of residual fluid
The amount of residual reflects gastric emptying
time and indicates whether the feeding should
continue.
Return residual fluid to stomach via tube Residual contents are returned to the stomach
and proceed to feeding.
because they contain valuable electrolytes and
digestive enzymes.
Nursing Alert
If amount of the residual exceed hospital In the case of non present of residual, you
protocol or Dr.s order, refer to these order.
should check placement carefully.
Residual over 120 mL may be caused by feeding
too fast or taking time more to digest. Hold
feeding for 2 hours, and recheck residual.
b. Injecting 10- 20 mL of air into tube:
Inject 3-5 mL of air for children
Attach syringe filled with air to tube
A whooshing or gurgling sound usually indicates
Inject air while listening with stethoscope
that the tube is in the stomach
over left upper quadrant
103
Care Action
c. Taking an x-ray or ultrasound
Rationale
It may be needed to determine the tubes
placement
Fig. 79
a. Aspiration of stomach secretion
(from Caroline : Textbook of Basic Nursing, 1999, p.355)
Care Action
Rationale
Intermittent or Bolus feeding
Using a feeding bag:
7. Feeding the following
1) Hang the feeding bag set-up 12 to 18 inches
above the stomach. Clamp the tubing.
2) Fill the bag with prescribed formula and prepare
the tubing by opening the clamp. Allow the
feeding to flow through the tubing . Reclamp the
tube.
3) Attach the end of the set-up to the gastric tube. Rapid feeding may cause nausea and abdominal
Open the clamp and adjust flow according to the
cramping.
Dr.s order.
4) Add 30-60 mL of water to the feeding bag as Water clears the tube, keeping it patent.
feeding is completed. Allow the flow into basin.
5) Clamp the tube and disconnect the feeding Clamping when feeding is completed prevents air
set-up.
from entering the stomach
Using the syringe:
7. Feeding the following
1) Clamp the tube. Insert the tip of the large syringe
with plunger, or bulb removed into the gastric
tube.
2) Pour feeding into the syringe
104
Care Action
3) Raise the syringe 12 to 18 inches above the
stomach. Open the clamp.
4) Allow feeding to flow slowly into the stomach.
Raise and lower the syringe to control the rate of
flow.
5)Add additional formula to the syringe as it
empties until feeding is complete
8. Termination feeding:
1) Terminate feeding when completed.
2) Instill prescribed amount of water
3) Keep the clients head elevated for 20-30 minutes.
9. Mouth care:
1) Provide mouth care by brushing teeth
2) Offer mouthwash
3) Keep the lips moist
10. Clean and replace equipments to proper place
Rationale
Gravity promotes movement of feeding into the
stomach
Controlling administration and flow rate of
feeding prevents air from entering the stomach
and nausea and abdominal cramping from
developing
12. Document date, time, amount of residual, Documentation provides continuity of care
amount of feeding, and clients reaction to Giving
signature
maintains
professional
feeding. Sign the chart
accountability
105
Purpose:
1. To promote wound granulation and healing
2. To prevent micro-organisms from entering wound
3. To decrease purulent wound drainage
4. To absorb fluid and provide dry environment
5. To immobilize and support wound
6. To assist in removal of necrotic tissue
7. To apply medication to wound
8. To provide comfort
Equipments required:
1. Sterile gloves (1)
2. Gauze dressing set containing scissors and forceps (1)
3. Cleaning disposable gloves if available (1)
4 Cleaning basin(optional) (1) as required
5. Plastic bag for soiled dressings or bucket (1)
6. Waterproof pad or mackintosh (1)
7. Tape (1)
8. Surgical pads as required
9. Additional dressing supplies as ordered, e.g. antiseptic ointments, extra dressings
10. Acetone or adhesive remover (optional)
11. Sterile normal saline (Optional)
106
Procedure:
Care Action
1. Explain the procedure to the client
2. Assemble equipments
Rationale
Providing information fosters his/her cooperation
and allays anxiety.
Organization
facilitates
accurate
skill
performance
To prevent the spread of infection
The order clarifies type of dressing
To provide privacy
To prevent bed sheets from wetting body
substances and disinfectant
Proper positioning provides for comfort.
8.Place opened, cuffed plastic bag near working Soiled dressings may be placed in disposal bag
area.
without contamination outside surfaces of bag.
9. Loosen tape on dressing . Use adhesive remover It is easier to loosen tape before putting in gloves.
if necessary. If tape is soiled, put on gloves.
10.
1) Put on disposable gloves
Using clean gloves protect the nurse when
handling contaminated dressings.
2) Removed soiled dressings carefully in a clean to Cautious removal of dressing(s) is more
less clean direction.
comfortable for client and ensures that drain is
3) Do not reach over wound.
not removed if it is present.
4) If dressing is adhering to skin surface, it may be Sterile saline provides for easier removal of
moistened by pouring a small amount of sterile
dressing.
saline or NS onto it.
5) Keep soiled side of dressing away from clients
view.
11. Assess amount, type, and odor of drainage.
Wound healing process or presence of infection
should be documented.
12.
1) Discard dressings in plastic disposable bag.
Proper disposal dressings prevent the spread of
2) Pull off gloves inside out and drop it in the bag
microorganisms by contaminated dressings.
when your gloves were contaminated extremely
by drainage.
13.Cleaning wound:
a. When you clean wearing sterile gloves:
1) Open sterile dressings and supplies on work area Supplies are within easy reach, and sterility is
using aseptic technique.
maintained.
Sterility of dressings and solution is maintained.
2) Open sterile cleaning solution
3) Pour over gauze sponges in place container or
over sponges placed in sterile basin.
4) Put on gloves.
5) Clean wound or surgical incision
Clean from top to bottom or from center Cleaning is done from least to most contaminated
outward
area.
107
Care Action
5) Use one gauze square for each wipe,
discarding each square by dropping into plastic
bag. Do not touch bag with gloves.
Clean around drain if present, moving from
center outward in a circular motion.
Use one gauze square for each circular
motion.
b. When you clean using sterile forceps:
1) Open sterile dressings and supplies on work area
using aseptic technique.
2) Open sterile cleaning solution
3) Pour over gauze sponges or cottons in place
container or over sponges or cottons placed in
sterile basin.
4) Clean wound or surgical incision:
Follow the former procedure using sterile gloves.
14. Dry wound or surgical incision using gauze
sponge and same motion.
15. Apply antiseptic ointment by forceps if ordered.
Rationale
Previously cleaned area is re-contaminated.
Purpose:
1. To relieve dyspnoea
2. To reduce or prevent hypoxemia and hypoxia
3. To alleviate associated with struggle to breathe
Sources of Oxygen:
Therapeutic oxygen is available from two sources
1. Wall Outlets(; Central supply)
2. Oxygen cylinders
Nursing Alert
Explain to the client the dangers of lighting matches or smoking cigarettes, cigars, pipes. Be sure
the client has no matches, cigarettes, or smoking materials in the bedside table.
Make sure that warning signs (OXYGEN- NO SMOKING) are posted on the clients door and
above the clients bed.
Do not use oil on oxygen equipment.( Rationale: Oil can ignite if exposed to oxygen.)
With all oxygen delivery systems, the oxygen is turned on before the mask is applied to the client.
Make sure the tubing is patent at all times and that the equipment is working properly.
Maintain a constant oxygen concentration for the client to breathe; monitor equipment at regular
intervals.
Give pain medications as needed, prevent chilling and try to ensure that the client gets needed rest.
Be alert to cues about hunger and elimination.( Rationale: The clients physical comfort is
important.)
Watch for respiratory depression or distress.
Encourage or assist the client to move about in bed. ( Rationale: To prevent hypostatic pneumonia
or circulatory difficulties.) Many clients are reluctant to move because they are afraid of the oxygen
apparatus.
Provide frequent mouth care. Make sure the oxygen contains proper humidification.( Rationale:
Oxygen can be drying to mucous membrane.)
Discontinue oxygen only after a physician has evaluated the client. Generally, you should not
abruptly discontinue oxygen given in medium-to-high concentrations( above 30%). Gradually
decrease it in stages, and monitor the clients arterial blood gases or oxygen saturation level.
( Rationale: These steps determine whether the client needs continued support.)
Always be careful when you give high levels of oxygen to a client with COPD. The elevated levels of
oxygen in the patients body can depress their stimulus to breathe.
Never use oxygen in the hyperventilation patient.
Wear gloves any time you might come into contact with the clients respiratory
secretions.( Rationale: To prevent the spread of infection).
109
Equipments required:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
NOTE:
Method
Nasal cannula
bring
less
anxiety
4
32-36 %
44 %
Allows client to talk and eat
5
36-40 %
Mouth breathing does not
6
40-44 %
affect the concentration of
delivered oxygen
5-6
40 %
Can
deliver
high May cause anxiety
concentration of oxygen able to lead hotness and
6-7
50 %
more than nasal cannula
claustrophobic
7-8(-10) 60 %
may cause dirty easier, so
cleansing
is
needed
frequently
should be removed while
eating and talking
Tight seal or long wearing
can cause skin irritation
on face
There are another high flow devices such as venture mask, oxygen hood and tracheostomy mask. You
should choose appropriate method of oxygen administration with Drs prescription and nursing
assessment.
110
Rationale
To avoid medical error
To prevent the spread of infection
Providing information fosters the clients
cooperation and allays his/her anxiety
Organization
facilitates
accurate
skill
performance
12. Assess the patients response to oxygen and Anxiety increases the demand for oxygen
comfort level.
13. Dispose of gloves if you wore and perform hand To prevent the spread of infection
hygiene
14.Place No Smoking signboard at entry into the The sign warns the client and visitors that
room
smoking is prohibited because oxygen is
combustible
15.Document the following:
Documentation provides coordination of care
Date, time, method, flow rate, respiratory Sometimes oxygen inhalation can bring oxygen
condition and response to oxygen
intoxication.
16. Sign the chart
To maintain professional accountability
111
Care Action
17. Report to the senior staff
Rationale
To provide continuity of care and confirm the
clients condition
Sterile water needs to be added when the level
falls below the line on the humidification
container.
Nares may become dry and irritated and required
the use of a water-soluble lubricant.
In long use cases, evaluate for pressure sores over
ears, cheeks and nares.
Nursing Alert
After used the nasal cannula, you should cleanse it as follows:
1. Soak the cannula in salvon water for an hour
2. Dry it properly
3. Cleanse the tip of cannula by spirit swab before applying to client
112
Respiratory
secretions
are
considered
contaminated
Documentation provides for coordination of care
To maintain professional accountability
To assess the respiratory condition and find out
any abnormalities as soon as possible
11.Check for reddened pressure areas under the The straps, when snug, place pressure on the
straps
underlying skin areas
Nursing Alert
The Simple mask is a low-flow device that providers an oxygen concentration in the 40-60% range, with a
liter flow 6 to 10 L/m. BUT! The simple mask requires a minimum oxygen flow rate of 6 L/m to prevent
carbon dioxide buildup
113
114
115
Step the principle procedure for safety and the best-efficacy based on 5 Rights: Right drug, Right dose,
Right route, Right time, Right client( ,Right form)
Perform hand hygiene. (Rationale: to prevent the spread of infection)
Collect prescription and ensure that the client is available and understandable to take the
medication.(Rationale: to secure informed-consent)
Check the medicine as the points: name, components, dose, expiry date(Rationale: to provide safe
and efficient medication)
Prior to administration ensure you are knowledgeable about the drug(s) to be administered. This
should include: therapeutic use, normal dosage, routes/forms, potential side effects,
contra-indications.(Rationale: to ensure safety and well-being of client and enable you to identify
any errors in prescribing)
Confirm identity of client verbally and with chart, prescription, checking full name, age, date of
birth: Right client.(Rationale: to ensure that the correct drug is being administered to the correct
client)
Ensure that the medication has not been given till that time(Rationale: to ensure right dose)
116
Purposes:
1. To prevent the disease and take supplement in order to maintain health
2. To cure the disease
3. To promote the health
4. To give palliative treatment
5. To give as a symptomatic treatment
Equipments required:
1. Steel tray (1)
2. Drinking water in jug (1)
3. Drs prescription
4. Medicine prescribed
5. Medicine cup (1)
6. Pill crusher/ tablet cutter if needed
7. Kidney tray/ paper bag (to discard the waste) (1)
117
Procedure:
Care Action
1. Perform hand hygiene
2. Assemble all equipments
Rationale
To prevent the spread of infection
Organization
facilitates
accurate
skill
performances
3. Verify the medication order using the clients To reduce the chance of medication errors
kardex. Check any inconsistencies with Dr. before
administration
4. Prepare one clients medication at a time
Lessen the chances for medication errors
5. Proceed from top to bottom of the kardex when This ensures that you do not miss any medication
preparing medications
orders
6. Select the correct medication from the shelf or Comparing medication to the written order is a
drawer and compare the label to the medication
check that helps to prevent errors
order on the kardex
a. From the multidose bottle:
Pour a pill from the multidose bottle into the Pouring medication into the lid eliminates
handling it.
container lid and transfer the correct amount to
a medicine cup.
Unit dose wrappers keep medications clean and
b. In the case of unit packing:
safe.
Leave unit dose medication in wrappers and
place them in a medication cup
c. Liquid medications:
Measure liquid medications by holding the Holding a cup at eye level to pour a liquid gives
the most accurate measurement.
medicine cup at eye level and reading the level
at the bottom of the meniscus. Pour from the Pouring away from the label and wiping the lip
helps keep the label readable
bottle with the label uppermost and wipe the
neck if necessary
7. Recheck each medication with the Kardex
To ensure preparation of the correct dose
8. When you have prepared all medications on a To check all medications three times to prevent
tray, compare each one again to the medication
errors
order.
9. Crush pills if the client is unable to swallow
them:
1) Place the pill in a pill crusher and crush the pill Crushed medications are often easier to swallow
until it is in powder form
Nursing Alert
Do not crush time-release capsules or Enteric-coated tablets that are crushed may
enteric-coated tablets
irritate the stomachs mucosal lining. Opening
and crushing the contents of a time-release
capsule may interfere with its absorption
2) Dissolve substance in water or juice, or mix with
applesauce to mask the taste
3) If no need to crush, cut tablets at score mark only
10.Bring medication to the client you have Hospital/ Agency policy considers 30 minutes
prepared.
before or after the ordered time as an acceptable
variation
118
Care Action
Rationale
11. Identify the client before giving the medication:
To abide by Five rights to prevent medication
a. Ask the client his/her name
errors
b. Ask a staff member to identify the client
c. Check the name on the identification bracelet Checking the identification bracelet is the most
if available
reliable
12. Complete necessary assessments before giving Additional checking includes taking vital signs
medications
and allergies to medications, depending on the
medications action
13. Assist the client to a comfortable position to take Sitting as upright as possible makes swallowing
medications
medication easier and less likely to cause
aspiration
14. Administer the medication:
1) Offer water or fluids with the medication
You should be aware of any fluid restrictions that
exist
2) Open unit dose medication package and give
the medication to the medicine cup
3) Review the medications name and purpose
4) Discard any medication that falls on the floor
5) Mix powder medications with fluids at the Powdered forms of drugs may thicken when
bedside if needed
mixed with fluid. You should give them
immediately
6) Record fluid intake on the balance sheet
Recording fluid taken with medications
maintains accurate documentation
15. Remain with the client until he/she has taken Be sure that the client takes the medication.
all medication. Confirm the clients mouth if
Leaving medication at the bedside is unsafe.
needed.
16.Perform hand hygiene
To prevent the spread of infection
17. Record medication administration on the
appropriate form:
1) Sign after you have given the medication
Documentation provides coordination of care and
giving
signature
maintains
professional
accountability
2) If a client refused the medication, record To verifies the reason medications were omitted
according to your hospital/agency policy on the
as well as the specific nursing assessments
record.
needed to safely administer medication
3) Document vital signs or particular assessments To confirm medications action
according to your hospitals form
4) Sign in the narcotic record for controlled Federal law regulates special documentation for
substances when you remove them from the
controlled narcotic substances
locked area( e.g, drawer or shelf).
18. Check the client within 30 minutes after giving To verify the clients response to the medication
medication.
Particularly, you should check the response after
administered pain killer whether if the
medication relieves pain or not.
119
Purpose:
as Administering oral medication
Equipments required:
1. Clients kardex and chart
2. Medication prescribed
3. Medicine cup (1)
4. Water or another fluids as needed
5. Mortar and pestle or pill crusher if an order to crush medications has been obtained ()
6. Disposable gloves (1): if available
7. Large syringe (20-30 mL) (1)
8. Small syringe (3-5 mL) (1)
9. Stethoscope (1)
120
Procedure:
Care Action
Rationale
1. Confirmation the medication:
1) Check the name, dosage, type, time of medication Be sure to administer the correct medication and
with the clients kardex.
dosage to the correct client
2) If you are going to give more than one
medication, make sure they are compatible
2. Check the kardex and the clients record for You cannot administer a medication to which the
allergies to medications
client previously experienced an allergic
reaction
3. Perform hand hygiene
To prevent the spread of infection
4. Assemble all equipments
Organization helps to eliminate the possibility of
medication errors
5. Set up medication following the Five right of Strictly adhere to safety precautions to decrease
administration
the possibility of errors
6. Explain the procedure
To allay his/her anxiety
7. Put on gloves if available
To maintain standard precautions which indicate
to avoid possibility to be infected by any body
fluids or secretions
8. Check the placement of the nasal-gastric tube
Ensure that medication will be delivered into the
1) Connect a small syringe to the end of tube
stomach
2) Gently aspirate the gastric juice or endogastric
If you cannot confirm the tubings placement,
substances by a syringe
consult senior staffs and be sure the correct
placement.
Nursing Alert
Do not aspirate if the client has a button type
Aspiration can damage the antireflux valve
gastric-tube
9. After checking for the gastric-tubes placement, Pinch or clamp the tubing prevents endogastric
pinch or clamp the tubing and remove the syringe
substances form escaping through the tubing
Ensure that no air enters the stomach, causing
discomfort for the client
10. Administering medications:
1) Remove the plunger from the large syringe and
reconnect the syringe to the tube
2) Release the clamp and pour the medication into
the syringe
3) If the medication does not flow freely down the
tube, insert the plunger and gently apply a slight
pressure to start the flow.
4) If medication flow does not start, determine if the
gastric-tube of plugged.
5) After you have administered the medication, To clear the tube and decrease the chance of the
flush the tube with 15 to 30 ml of water.
tubing becoming clogged
6) Clamp the tubing and remove the syringe
To prevent the medication and water from
escaping
7) Replace the tubing plug. If feeding is continued,
reconnect the tubing to the feeding tubing
121
Care Action
Rationale
11. Assist the client to a comfortable position
To provide comfort
12. Document administration of gastric-tube Documentation provides continuity of care and
feeding of medication and sign
giving
signature
maintain
professional
accountability
122
Purpose:
1. To prepare medication for administration of medication by sterilized method
Equipments required:
1. Medication chart
2. Sterile syringe (1)
3. Sterile needle (1)
4. Second needle (optional)
5. Spirit swab
6. Ampoule of medication prescribed
7. Ampoule cutter if available (1)
8. Kidney tray (1)
9. Steel Tray (1)
10.Container for discards if possible (1)
NOTE:
123
Procedure:
Care Action
1.Gather equipments. Check the medication order
against the original Dr.'s order according to
hospital/ agency policy.
2.Perform hand hygiene
3.Tap the stem of ampoule or twist your wrist
quickly while holding the ampoule vertically.
(Fig. 83 A, B )
4. Wipe the neck around of the ampoule by spirit
swab
5.After drying spirit, put and round a ampoule
cutter to the neck of the ampoule roundly.
6. Put spirit swab to the neck of the ampoule. Use a
snapping motion to break off the top of the
ampoule along the pre-scored line at its neck.
Always break away from your body.
7.
1) Remove the cap from the needle by pulling it
straight off.
2) Hold the ampoule by your non-dominant hand
(usually left hand) and insert the needle into the
ampoule, being careful not to touch the rim.
Rationale
This comparison helps to identify that may have
occurred when orders were transcribed.
To prevent the spread of infection
This facilitates movement of medication in the
stem to the body of the ampoule.
To prevent entering of dust and microorganisms
To cut smoothly and avoid making any shattered
glass fragments
This protects the nurses' face and finger from any
shattered glass fragments.
Care Action
8. Withdraw medication in the amount ordered plus
a small amount more (- 30 %). Do not inject air
into solutions.
1) Insert the tip of the needle into the ampoule.
(Fig. 84 )
2) Withdraw fluid into the syringe Touch the
plunger at the knob only. (Fig. 85 )
9.
1) Do not expel any air bubbles that may form in
the solution.
2) Wait until the needle has been withdrawn to tap
the syringe and expel the air carefully.
3) Check the amount of medication in the syringe
and discard any surplus.
10.Discard the ampoule in a kidney tray or a
suitable container after comparing with the
medication chart.
Rationale
By withdrawing a small amount more of
medication, any air bubbles in the syringe can be
displaced once the syringe is removed.
Handling the plunger at the knob only will keep
the shaft of the plunger sterile.
125
Purpose:
1. To prepare medication for administration of medication by sterilized method
Equipments required:
1. Medication chart
2. Sterile syringe (1)
3. Sterile needle (1)
Size depends on medication being administration and client
4. Vial of medication prescribed
5. Spirit swabs
6. Second needle (optional)
Size depends on medication being administration and client
7. Kidney Tray (1)
8. Steel Tray (1)
126
Procedure:
Care Action
1.Gather equipments. Check medication order
against the original Dr.s order according to
agency policy.
2. Perform hand hygiene.
3. Remove the metal or plastic cap on the vial that
protects the rubber stopper.
4. Swab the rubber top with the spirit swab.
Rationale
This comparison helps to identify errors that may
have occurred when orders were transcribed.
To prevent the spread of infection
The metal or plastic cap prevents contamination
of the rubber top.
Sprit removes surface bacteria contamination.
This should be done the first the rubber stopper is
entered, and with any subsequent re-entries into
the vial.
Before fluid is removed, injection of an equal
amount of air is required to prevent the formation
of a partial vacuum because a vial is a sealed
container. If not enough air is injected, the
negative pressure makes it difficult to withdraw
the medication .
Air bubbled through the solution could result in
withdrawal of an inaccurate amount of
medication.
site
127
Care Action
Rationale
9. Removal of air:
1) If any bubbles accumulate in the syringe , tap the Removal of air bubbles is necessary to ensure that
barrel of the syringe sharply and move the needle
the dose of medication is accurate.
past the fluid into the air space to re-inject the air
bubble into the vial.
2) Return the needle tip to the solution and
continue withdrawing the medication.
10. After the correct dose is withdrawn, remove the This prevents contamination of he needle and
needle from the vial and carefully replace the cap
protects the nurse against accidental needle
over the needle.
sticks.
Nursing Alert
Some agencies recommended changing needles, if This method can decrease possibility of
needed to administer the medication, before
contamination by the first needle and maintain
administering the medication.
sharp of the tip on needle
11. If a multidose vial is being used, label the vial Because the vial is sealed, the medication inside
with the date and time opened, and store the vial
remains sterile and can be used for future
containing the remaining medication according to
injections.
agency policy.
12. Perform hand hygiene.
To prevent the spread of infection
128
Purpose: To prevent own finger or another person by needle from sticking accidentally
Procedure:
Action
1. Until giving injection:
1) Before giving the injection, place the needle cover
on a solid, immovable object such as the rim of a
bedside table or big tray.
2) The open end of the cap should face the nurse
and be within reach of the nurses dominant, or
injection hand.
3) Give the injection.
2. Recapping: (Fig. 87)
1) Place the tip of the needle at the entrance of the
cap.
2) Gently slide the needle into the needle cover.
3. Once the needle is inside the cover, use the
objects
resistance to completely cover the
needle.
4. Dispose of the needle at the first opportunity.
Rationale
Plan safe handling and disposal if needles before
beginning the procedure.
129
Purpose:
1.To relieve symptoms of illness
2. To promote and prevent from disease
3. To treat the disease accordingly
Contraindication:
IM injections may be contraindicated in clients with;
Impaired coagulation mechanisms
Occlusive peripheral vascular disease
Edema
Shock
After thrombolytic therapy
during myocardial infarction
(Rationale: These conditions impair peripheral absorption)
Equipments required:
1. Clients chart and kardex
2. Prescribed medication
3. Sterile syringe (3-5 mL) (1)
4. Sterile needle in appropriate size: commonly used 21 to 23 G with 1.5(3.8cm) needle (1)
5. Spirit swabs
6. Kidney tray (1)
7. Disposable container (1)
8. Ampoule cutter if available (1)
9. Steel Tray (1)
10. Disposable gloves if available (1)
11. Pen
Nursing Alert
The needle may be packaged separately or already attached to the sterile syringe. Prepackaged loaded
syringes usually have a needle that is 1 long. BUT! check the package with care before open it.
The needles used for IM injections are longer than subcutaneous needles (Rationale: Needles must reach
deep into the muscle.)
Needle length also depends on the injection site, clients size, and amount of subcutaneous fat covering
the muscle.
The needle gauge for IM injections should be larger to accommodate viscous solutions and suspensions.
130
Nursing Alert
Selection of appropriate site for IM injection
131
Procedure:
Rationale
Care Action
1. Assemble equipments and check the Dr.s order
132
Care Action
Rationale
3) Place a small, dry gauze or spirit swab on a clean, To prepare a dry gauze or spirit swab to give light
nearby surface or hold it between the fingers of
pressure immediately after I.M.
your non-dominant hand.
9. Remove the needle cap by pulling it straight off
This technique lessens the risk of accidental
needle-stick and also prevents inadvertently
unscrewing the needle from the barrel of the
syringe
10. Spread the skin at the injection site using your This makes the tissue taut and facilitates needle
non-dominant hand
entry. You may minimize his/her discomfort
11. Hold the syringe in your dominant hand like a This position keeps your fingers off the plunger,
pencil or dart.
preventing accidental medication loss while
inserting the needle
12. Insert the needle quickly into the tissue at a 90 A quick insertion is less painful
degree angle
This angle ensures you will enter muscle tissue.
13. Release the skin and move your non-dominant To prevent movement of the syringe
hand to steady the syringes lower end
14. Aspiration blood:
1) Aspirate gently for blood return by pulling back A blood return indicates IV needle placement
on the plunger with your dominant hand
Possibly a serious reaction may occur if a drug
intended for intramuscular use is injected into a
vein
2) If blood enters the syringe on aspiration, Blood contaminates the medication, which must
withdraw the needle and prepare a new
be redrawn
injection with a new sterile set-up.
15. If no blood appears, inject the medication at a Rapid injection may be painful for the client.
slow and steady rate(; 10 seconds/ mL of
Injecting slowly reduces discomfort be allowing
medication)
time for the solution to disperse in the tissues
16. Remove the needle quickly at the same angle Slow needle withdrawal may be uncomfortable
you inserted it
for the client
17. Massage the site gently with a small, dry gauze Massaging the site promotes medication
or spirit swab, unless contraindicated for specific
absorption and increases the clients comfort.
Medication. If there are contraindications to Do not massage a heparin site because of the
massage, apply gentle pressure at the site with a
medications anticoagulant action
small, dry gauze or a spirit swab.
Light pressure causes less trauma and irritation
the tissues. Massage can force medication into the
subcutaneous tissues in some medications
18. Discard the needle:
1) Do not recap the needle
Most accidental needle-sticks occur while
recapping needles
2) Discard uncapped needle and syringe in Proper disposal prevents injury
appropriate container if available
19. Assist the client to a position of comfort
To facilitate comfort and make him/her relax
20. Remove your gloves and perform hand hygiene To prevent the spread of infection
133
Care Action
Rationale
21.Recording:
Record the medication administered, dose, date,
time, route of administration, and IM site on the
appropriate form.
22. Evaluation the clients response:
1) Check the client's response to the medication
within an appropriate time
2) Assess the site within 2 to 4 hours after
administration
Nursing Alert
No more than 5 mL should be injected into a single site for an adult with well-developed muscles
If you must inject more than 5 mL of solution, divide the solution and inject it at two separate sites.
The less developed muscles of children and elderly people limit the intramuscular injection to 1 to 2 mL
Special considerations for pediatric:
The gluteal muscles can be used as the injection site only after a toddler has been walking for about 1
year
Special considerations for elder:
IM injection medications can be absorbed more quickly than expected because elder clients have
decreased muscle mass.
134
NOTE:
135
Procedure:
Care Action
1. Assemble all equipments and bring to bedside.
Rationale
Having equipment available saves time and
facilitates accurate skill performance
Ensures that the client receives the correct I.V.
solution and medication as ordered by Dr.
Explanation allays his/her anxiety and fosters
his/her cooperation
To prevent the spread of infection
136
Care Action
Rationale
4) Check to be sure that the radial pulse is still Too much tight the arm makes the client
present
discomfort.
Interruption of the arterial flow impedes venous
filling.
8.Palpation the vein
1) Ask the client to open and close his/her fist.
Contraction of the muscle of the forearm forces
blood into the veins, thereby distending them
further.
2) Observe and palpate for a suitable vein
To reduce several puncturing
3) If a vein cannot be felt and seen, do the following: Lowering the arm below the level of the heart,
a. Release the tourniquet and have the client lower
tapping the vein, and applying warmth help
his/her arm below the level of the heart to fill the
distend veins by filling them with blood.
veins. Reapply tourniquet and gently over the
intended vein to help distend it
b. Tap the vein gently
c. Remove tourniquet and place warmed-moist
compress over the intended vein for 10-15
minutes.
Care must be used when handling any blood or
body fluids to prevent transmission of HIV and
other blood-born infectious disease
10. Cleanse the entry site with an antiseptic Cleansing that begins at the site of entry and
solution( such as spirit) according to hospital
moves outward in a circular motion carries
policy.
organisms away from the site of entry
a. Use a circular motion to move from the center Organisms on the skin can be introduced into the
to outward for several inches
tissues or blood stream with the needle.
b. Use several motions with same direction as
from the upward to the downward around
injection site approximate 5-6 inches
9. Put on clean gloves if available.
Care Action
Rationale
3) While following the course of the vein, advance
the needle or catheter into the vein.
4) A sensation can be felt when the needle enters
the vein.
5) When the blood returns through the lumen of the The tourniquet causes increased venous pressure
resulting in automatic backflow.
needle or the flashback chamber of the catheter,
advance either device 1/8 to 1/4 inch farther into
the vein.
6) A catheter needs to be advanced until hub is at Having the catheter placed well into the vein
the venipuncture site
helps to prevent dislodgement
13. Connecting to the tube and stabilizing the
catheter on the skin:
1) Release the tourniquet.
2) Quickly remove protective cap from the I.V. The catheter which immediately is connected to
the tube causes minimum bleeding and patency
tubing
of the vein is maintained
3) Attach the tubing to the catheter or needle
4) Stabilize the catheter or needle with nondominant hand
14.Starting flow
1) Release the clamp on the tubing
2) Start flow of solution promptly
Blood clots readily if I.V. flow is not maintained.
3) Examine the drip of solution and the issue If catheter accidentally slips out of vein, solution
around the entry site for sign of infiltration
will accumulate and infiltrate into surrounding
tissue
15. Fasten the catheter and applying the dressing:
1) Secure the catheter with narrow non-allergenic Non-allergenic tape is less likely to tear fragile
tape
skin
2) Place strictly sided-up under the hub and crossed The weight of tubing is enough to pull it out of the
over the top of the hub
vein if it is not well anchored.
There are various way to anchor the hub. You
should follow agency /hospital policy.
3) Loop the tubing near the site of entry
To prevent the catheter from removing
accidentally
16. Bring back all equipments and dispose in proper To prepare for the next procedure.
manner.
17. Remove gloves and perform hand hygiene
To prevent the spread of infection
18. If necessary, anchor arm to an arm board for An arm board helps to prevent change in the
support
position of the catheter in the vein. Site protectors
also will be used to protect the I.V. site.
19.Adjust the rate of I.V. solution flow according to Dr. prescribed the rate of flow or the amount of
Dr.s order
solution in day as required to the clients condition
Some medications are given very less amount.
You may use infusion pump to maintain the flow
rate
138
Care Action
Rationale
20. Document the procedure including the time, This ensures continuity of care
site , catheter size, and the clients response
21. Return to check the flow rate and observe for To find any abnormalities immediately
infiltration
Nursing Alert
You should have special consideration for the elderly and infant.
To Older adults
Avoid vigorous friction at the insertion site and using too much alcohol.(Rationale: Both can traumatize
fragile skin and veins in the elderly)
139
Purpose:
1. To protect injection site from infection
2. To provide safe IV therapy
3. To make the client comfort with IV therapy
4. To distinguish any complications as soon as possible
Equipments required:
1. Steel Tray (1)
2. Spirit swab
3. Dry gauze or cotton
4. Adhesive tape
5. IV infusion set if required
6. Kardex, clients record
7. Kidney tray (1)
140
Maintenance of I.V. system: General caring for the client with an I.V.
Care Action
1.Make at least hourly checks of the rate, tubing
connections, and amount and type of solution
present. If using an electronic infusion
device( pump or controller), check that all settings
are correct.
2. Watch for adverse reactions. One such problem
is infiltration, in which the I.V. solution infuses
into tissues instead of the vein. Check the insertion
site for redness, swelling, or tenderness hourly.
Document that you have checked the site.
3. Report any difficulty at once. The doctor may
order the I.V. line to be discontinued or to be
irrigated.
4. Safeguard the site and be aware of tubing and
pump during transfers, ambulation, or other
activities.
Rationale
Regular checking give proper amount
Checking before
incompatibility.
141
adding
avoid
having
Rationale
Ensure that correct solution will be used.
Incompatibilities may lead to precipitate
formation and can cause physical, chemical,
and therapeutic client changes.
Reveals need for client instruction.
If patency is occluded, a new I.V. access site may
be needed. Notify a doctor.
Adequate planning reduces risk of clot
formation in vein caused by empty I.V. bag.
Checking prevents medication error.
Care Action
17. Regulate flow to prescribed rate.
patency
and
143
Rationale
Deliver I.V. fluid as ordered.
Ink from markers may leach through polyvinyl
chloride containers.
Provides ongoing evaluation of client's fluid and
electrolyte status.
Provides ongoing evaluation of I.V. system.
Purpose:
1. To provide intermittent administration of medication
2. To administer medication under the urgent condition
Equipments required:
1. Clients chart and Kardex
2. Prescribed medication
3. Spirit swabs
4. Disposable gloves if available (1)
5. Kidney tray (1)
6. Steel Tray (1)
For flush
7. Saline vial or saline in the syringe (1)
8. Heparin flush solution (1)
9. Syringe (3-5 mL) with 21-25 gauge needle (1)
For Intermittent infusion
10. IV bag or bottle with 50-100 mL solution (1)
11. IV tubing set (1)
12. IV stand (1)
13. 21-23 gauge needle (1)
14. Adhesive tape
Nursing Alert
A heparin lock has an adapter which is attached to the hub(end)of the catheter.
An anticoagulant, approximately 2 mL heparin, is injected into the heparin lock.
To reduce the possibility of clotting , flush the heparin lock with 2-3 mL of saline 8 hourly (or once a every
duty); Saline lock.
Choose heparin lock or saline lock to decrease the possibility of making coagulation according to your
facilitys policy or Dr.s order.
144
Procedure:
Care Action
1. Perform hand hygiene
2. Assemble all equipments
3. Verify the medication order
4. Check the medication s expiration date
For Bolus Injection
5. Prepare the medication. If necessary, withdraw
from an ampoule or a vial
6. Explain the procedure to the client
7. Identify the client before giving the medication
8. Put on gloves
9. Cleanse the heparin lock port with a spirit swab
Rationale
To prevent the spread of infection
Organization facilities accurate skill performance
To reduce the chances of medication errors
Outdated medication may be ineffective
10.
1) Steady the heparin lock with your dominant
hand
2) Insert the needle of the syringe containing 1 Blood return on aspiration generally indicates
mL of saline into the center of the port
that the catheter is positioned in the vein.
3) Aspirate for blood return
4) Inject the saline
Saline clears the tubing of any heparin flush or
previous medication
5) Remove the needle and discard the syringe in Most accidental needle-sticks occur during
the sharps container without recapping it
recapping. Proper disposal prevents injury
11.
1) Cleanse the port again with a spirit swab
2) Insert the needle of the syringe containing the
medication
3) Inject the medication slowly
Rapid injection of medication can lead to speed
4) Withdraw the syringe and dispose of it properly
shock
12.
1) Cleanse the port with a spirit swab
Care Action
Rationale
11.
1) Cleanse the port again with a spirit swab
2) Insert the needle or needleless component
attached to the IV setup into the port
3) Attach it to the IV infusion pump or calculate the
flow rate
4) Regulate drip according to the prescribed
delivery time
5) Clamp the tubing and withdraw the needle when
all solution has been infused
6) Discard the equipments used safely according to
hospital/ agencys policy
12.
1) Cleanse the port with a spirit swab
To remove contaminants and prevents infection
2) Flush the lock with 1 mL heparin flush solution
via the port
according your hospital/agency policy.
Flush clears the lock of medication and keeps it
open
Some agencies recommend only a saline flush to
clear the lock
13. Remove gloves and perform hand hygiene
To prevent the spread of infection
14. Record:
Documentation provides coordination of care
1) Record the IV medication administration on the
appropriate form
2)Record the fluid volume on the clients balance
sheet
15. Check the clients response to the medication Drugs administered parenterally have rapid
within the appropriate time
onsets of action
146
Purpose:
1. To relieve respiratory insufficiency due to bronchospasm
2. To correct the underlying respiratory disorders responsible for bronchospasm
3. To liquefy and remove retained thick secretion form the lower respiratory tract
4. To reduce inflammatory and allergic responses the upper respiratory tract
5. To correct humidify deficit resulting from inspired air by passing the airway during the use of
mechanical ventilation in critically and post surgical patients
Types of nebulizer:
1. Inhaler or meterd-dose nebulizer
2. Jet nebulizer
3. Ultrasonic nebulizer
Nursing Alert
Teach the client how to use personnel device. (Rationale: To ensure appropriate self-care after discharge)
Avoid treatment immediately before and after meals.(Rationale: To decrease the chance of vomiting or
appetite suppression, especially with medication that cause the client to cough or expectorate or those
that are done in conjunction with percussion/ bronchial drainage )
147
a. Inhaler
Equipments required:
1. Dr.s order card, clients chart and kardex
2. Inhaler (1)
3. Tissue paper
4. Water, lip cream as required
Procedure:
Care Action
Rationale
1. Perform hand hygiene
To prevent the spread of infection
2. Prepare the medication following the Five rights Strictly observe safety precautions to decrease the
of medication administration:
possibility of a medication error
Right drug
Right dose
Right route
Right time
Right client
3. Explain to the client what you are going to do.
Providing explanation fosters his/her cooperation
and allays anxiety
4. Assist the client to make comfortable position in Upright position can help expanding the chest
sitting or semi-Fowler position.
5. Shake the inhaler well immediately prior to use
Shaking aerosolizes the fine particles
6. Spray once into the air.
To fill the mouthpiece
7. Instruction to the client:
The procedure is designed to allow the medication
1) Instruct the client to take a deep breath and
to come into contact with the lungs for the
exhale completely through the nose
maximum amount of time
2) The client should grip the mouthpiece with the
lips, push down on the bottle, and inhale as
slowly and deeply as possible through the mouth.
3) Instruct the client to hold his/her breath for adult
10 seconds and then to slowly exhale with pursed
lips
4) Repeat the above steps for each ordered puffs, This method achieve maximum benefits
waiting 5-10 seconds or as prescribed between
puffs.
5) Instruct the client to gargle and wipe the face if Gargling cleanse the mouth. When steroid
needed.
remains inside the mouth, infection of fungus
may occur.
8. Replace equipments used properly and discard To prepare for the next procedure prevent the
dirt.
spread of infection and
9. Perform hand hygiene.
To prevent the spread of infection
10.Document the date, time, amount of puffs, and Documentation provides continuity of care
response. Sign on the documentation
Giving
signature
maintains
professional
accountability
11. Report any findings to a senior staff.
To provide continuity of care
148
b. Ultrasonic Nebulizer
Equipments required:
1. Dr.s order card, clients chart and kardex
2. Ultrasonic nebulizer (1)
3. Circulating set-up (1)
4. Sterile water
5. Mouthpiece or oxygen mask (1)
6. Prescribed medication
7. Sputum mug if available (1)
8. Tissue paper
9. Water, lip cream as required
Procedure:
Care Action
1. Check the medication order against the original
Drs order
2. Perform hand hygiene
3. Prepare the medication following the Five rights
of medication administration:
Right drug
Right dose
Right route
Right time
Right client
4. Explain to the client what you are going to do
Rationale
To ensure that you give the correct medication to
the correct client.
To prevent the spread of infection
Strictly observe safety precautions to decrease the
possibility of a medication error
149
Care Action
Rationale
3) Encourage the client to partially cough and
expectorate any secretions loosed during the
treatment
8. After nebulization finished,
1) Turn off the nebulizer and take off the cord from
the electrical outlet.
2) Instruct the client to gargle and wipe the face if Gargling cleanse the mouth. When steroid
needed.
remains inside the mouth, infection of fungus
may occur.
Apply lip cream if needed.
Applying lip cream provide moisten on lips.
3) Soak the nebulizer cup and mouthpiece or To avoid contamination
oxygen mask in warm salvon water for an hour.
Disinfect the nebulizer by spirit swab.
4) Rinse and dry it after each use
To prepare for the next procedure
5) Replace equipments used properly and discard To prepare for the next procedure and prevent the
dirt.
spread of infection
9. Perform hand hygiene.
10.Document the date, time, type and dose of
medication, and response. Sign on the
documentation
11. Report any findings to a senior staff.
150
151
Nursing Alert
Collecting Specimen
You always should follow the principle steps as the following:
Label specimen tubes or bottles with the clients name, age, sex, date, time, inpatient no. and other data
if needed before collecting the specimen.
Always perform hand hygiene before and after collecting any specimen.
Always observe body substance precautions when collecting specimens
Collect the sample according your hospital/agent policy and procedure.
Clean the area involved for sample collection
Maintain the sterile technique if needed for sample or culture.
Transport the specimen to laboratory immediately
Be sure specimen is accompanied by specimen form or appropriate order form
Record the collection and forwarding of the sample to laboratory on the clients record
152
Purpose:
1. To examine the condition of client and assess the present treatment
2. To diagnose disease
Equipments required:
1. Laboratory form
2. Sterilized syringe
3. Sterilized needles
4. Tourniquet (1)
5. Blood collection tubes or specimen vials as ordered
6. Spirit swabs
7. Dry gauze
8. Disposable Gloves if available (1)
9. Adhesive tape or bandages
10. Sharps Disposal Container (1)
11. Steel Tray (1)
12. Ball point pen (1)
153
Procedure:
Care Action
1. Identify the patient.
Outpatient are called into the phlebotomy area
and asked their name and date of birth.
Inpatient are identified by asking their name
and date of birth.
2. Reassure the client that the minimum amount of
blood required for testing will be drawn.
3.Assemble the necessary equipment appropriate
to the client's physical characteristics.
4.Explain to the client about the purpose and the
procedure.
5.Perform hand hygiene and put on gloves if
available.
6. Positioning
1) Make the client to be seated comfortably or supine
position
2) Assist the client with the arm extended to form
a straight-line from shoulder to wrist.
3) Place a protective sheet under the arm.
7. Check the clients requisition form, blood collection
tubes or vials and make the syringe-needle ready.
Rationale
This information must match the requisition.
154
Care Action
4) After blood is drawn the desired amount,
release the tourniquet and ask the client to open
his/her fist.
5) Place a dry gauze over the puncture site and
remove the needle.
6) Immediately apply slight pressure. Ask the client
to apply pressure for at least 2 minutes.
7) When bleeding stops, apply a fresh bandage or
gauze with tape.
12.
1) Transfer blood drawn into appropriate blood
specimen bottles or tubes as soon as possible
using a needless syringe .
2)The container or tube containing an additive
should be gently inverted 5-8 times or shaking
the specimen container by making figure of 8.
13.Dispose of the syringe and needle as a unit into
an appropriate sharps container.
14. Label all tubes or specimen bottles with client
name, age, sex, inpatient no., date and time.
15.Send the blood specimen to the laboratory
immediately along with the laboratory order
form.
16. Replace equipments and disinfects materials if
needed.
17. Put off gloves and perform hand hygiene.
Rationale
NURSING ALERT
Factors to consider in site selection:
Extensive scarring or healed burn areas should be avoided.
Specimens should not be obtained from the arm on the same side as a mastectomy.
Avoid areas of hematoma.
If an I.V. is in place, samples may be obtained below but NEVER above the I.V. site.
Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.
Allow 10-15 minutes after a transfusion is completed before obtaining a blood sample.
Safety
Observe universal (standard ) precaution safety precautions. Observe all applicable isolation
procedures.
Needle are never recapped, removed, broken or bent after phlebotomy procedure.
Gloves are to be discarded in the appropriate container immediately after the procedure.
Contaminated surfaces must be cleaned with freshly prepared 10 % bleach solution. All surfaces are
cleaned daily with bleach.
In the case of an accidental needle-stick, immediately wash the area with an antibacterial soap,
express blood from the wound, and contact your supervisor.
155
156
Purpose:
1.To identify s disease-causing organisms
2. To detect the right antibiotics to kill the particular microorganisms
Equipments required:
1. Laboratory form
2. Sterilized syringes (10 mL): (2-3)
3. Sterilized needles
: (2-3)
4. Tourniquet (1)
5. Blood culture bottles or sterile tubes containing a sterile anticoagulant solution as required
6. Disinfectant : Povidon-iodine or spirit swabs
7. Dry gauze
8. Disposable gloves if available (1)
9. Adhesive tape or bandages
10. Sharps Disposal Container (1)
11. Steel Tray (1)
12. Ball point pen (1)
157
Procedure:
Nursing Alert
Your role is that of assistant. You are responsible to notify the proper client when the culture is to be done.
Use the following actions in assisting with blood cultures:
Care Action
1. Identify the patient.
2. Reassure the client that the minimum amount of
blood required for testing will be drawn.
3.Assemble the necessary equipment appropriate
to the client's physical characteristics.
4.Explain to the client about the purpose and the
procedure.
5. Label all tubes or specimen bottles with client
name, age, sex, inpatient no., date and time.
6.Perform hand hygiene and put on gloves if
available.
7. Protect the bed with a pad under the clients arm.
Rationale
This information must match the requisition.
To perform once properly without any
unnecessary collecting of blood
Organization
facilitates
accurate
skill
performance
Providing
explanation
fosters
his/her
cooperation and allays anxiety
To prevent the blood tubes or bottles from
misdealing.
To prevent the infection of spreading.
158
Purpose:
1. To diagnose illness
2. To monitor the disease process
3. To evaluate the efficacy of treatment
Nursing Alert
Label specimen containers or bottles before the client voids.(Rationale: Reduce handling after the
container or bottle is contaminated.)
Note on the specimen label if the female client is menstruating at that time.(Rationale: One of the tests
routinely performed is a test for blood in the urine. If the female client is menstruating at the time a
urine specimen is taken, a false-positive reading for blood will be obtained. )
To avoid contamination and necessity of collecting another specimen, soap and water cleansing of the
genitals immediately preceding the collection of the specimen is supported.(Rationale: Bacteria are
normally present on the labia or penis and the perineum and in the anal area.)
Maintain body substances precautions when collecting all types of urine specimen.(Rationale: To
maintain safety.)
Wake a client in the morning to obtain a routine specimen.(Rationale: If all specimen are collected at the
same time, the laboratory can establish a baseline. And also this voided specimen usually represents
that was collecting in the bladder all night. )
Be sure to document the procedure in the designated place and mark it off on the Kardex.(Rationale: To
avoid duplication.)
159
Procedure:
Care Action
1. Explain the procedure
2. Assemble equipments and check the specimen
form with clients name, date and content of
urinalysis
3. Label the bottle or container with the date,
clients name, department identification, and Drs
name.
4. Perform hand hygiene and put on gloves
5.Instruct the client to void in a clean receptacle.
6. Remove the specimen immediately after the
client has voided
7. Pour about 10-20 mL of urine into the labeled
specimen bottle or container and cover the bottle
or container
Rationale
Providing information fosters his/her cooperation
Organization
facilitates
accurate
skill
performance
Ensure that the specimen collecting is correct
Ensure correct identification and avoid mistakes
160
Purpose:
1. To detect kidney and cardiac diseases or conditions
2. To measure total urine component
Equipments required:
1. Laboratory form
2. Bedpan or urinal (1)
3. 24 hours collection bottle with lid or cover (1)
4. Clean measuring jar (1)
5. Disposable gloves if available (1)
6. Paper issues if available
7. Ballpoint pen (1)
Procedure:
Care Action
1. Explain the procedure
2. Assemble equipments and check the specimen
form with clients name, date and content of
urinalysis
3. Label the bottle or container with the date,
clients name, department identification, and Drs
name.
4. Instruct the client:
1) Before beginning a 24 hour urine collection, ask
the client to void completely.
2) Document the starting time of a-24 hour urine
collection on the specimen form and nursing
record.
3) Instruct the client to collect all the urine into
a large container for the next 24 hours.
4) In the exact 24 hours later, ask the client to void
And pour into the large container.
5) Measure total amount of urine and record it on
the specimen form and nursing record.
6) Document the time when finished the collection
5. Sending the specimen:
1) Perform hand hygiene and put on gloves if
available.
2) Mix the urine thoroughly
Rationale
Providing information fosters his/her cooperation
Organization
facilitates
accurate
skill
performance
Ensure that the specimen collecting is correct
Ensure correct identification and avoid mistakes
161
Care Action
Rationale
3) Collect some urine as required or all the urine in Ensure the client voids enough amount of the
a clean bottle with lid.
urine for the required tests
4) Transfer it to the laboratory with the specimen Covering the bottle retards decomposition and it
form immediately.
prevents added contamination.
Substances in urine decompose when exposed to
air. Decomposition may alter the test results
6.Dispose of used equipment or clean them. Remove To prevent the spread of infection
gloves and perform hand hygiene.
7.Document the procedure in the designated place To avoid duplication
and mark it off on the Kardex.
Documentation provides coordination of care
162
Purpose:
Care Action
1. Assemble equipments. Label the container.
Rationale
facilitates
Organization
accurate
skill
performance
2. Explain the procedure to the client
Providing information fosters his/her cooperation
3. Perform hand hygiene and put on gloves if To prevent the spread of infection
available.
4. Clamp the tubing:
Collecting urine from the tubing guarantees a
1) Clamp the drainage tubing or bend the tubing
fresh urine.
2) Allow adequate time for urine collection
Nursing Alert
You should not clamp longer than 15minutes
Long-time clamp can lead back flow of urine and
is able to cause urinary tract infection
5. Cleanse the aspiration port with a spirit swab or Disinfecting the port prevents organisms from
another disinfectant swab (e.g., Betadine swab)
entering the catheter.
6. Withdrawing the urine:
This technique for uncontaminated urine
1) Insert the needle into the aspiration port
specimen, preventing contamination of the clients
2) Withdraw sufficient amount of urine gently into
bladder
the syringe
7.Transfer the urine to the labeled specimen Careful labeling and transfer prevents
container
contamination or confusion of the urine specimen
Nursing Alert
The container should be clean for a routine Appropriate container brings accurate results of
urinalysis and be sterile for a culture
urinalysis.
8.Unclamp the catheter
The catheter must be unclamped to allow free
urinary flow and to prevent urinary stasis.
9.Prepare and pour urine to the container for Proper packaging ensures that the specimen is
transport
not an infection risk
10. Dispose of used equipments and disinfect if To prevent the spread of infection
needed. Remove gloves and perform hand
hygiene
11.Send the container to the laboratory
Organisms grow quickly at room temperature
Immediately
12.Document the procedure in the designated place To avoid duplication
and mark it off on the Kardex.
Documentation provides coordination of care
163
Purpose:
1. To collect uncontaminated urine specimen for culture and sensitivity test
2. To detect the microorganisms causes urinary tract infection (; UTI)
3. To diagnose and treat with specific antibiotic
Equipments required:
1. Laboratory form
2. Sterile gloves (1)
3. Sterile culture bottle with label as required
4. Sterile kidney tray or sterile container with wide mouthed if needed
5. Bed pan if needed (1)
6. Paper tissues if needed
7. Ballpoint pen (1)
Procedure:
Care Action
1. Assemble equipments and check the specimen
form with clients name, date and content of
urinalysis
2. Label the bottle or container with the date,
clients name, department identification, and Drs
name.
3. Explain the procedure to the client
4. Instruct the client:
1) Instruct the client to clean perineum with soap
and water
2) Open sterilized container and leave the cover
facing inside up
3) Instruct the client to void into sterile kidney tray
or sterilized container with wide mouth
4) If the client is needed bed-rest and needs to pass
urine more, put bed pan after you collected
sufficient amount of sterile specimen
5. Remove the specimen immediately after the
client has voided. Obtain 30-50 mL at midstream
point of voiding
Rationale
facilitates
Organization
accurate
skill
performance
Ensure that the specimen collecting is correct
Ensure correct identification and avoid mistakes
Care Action
8. Dispose of used equipment or clean them.
Remove gloves and perform hand hygiene.
9. Send the specimen bottle or container to the
laboratory immediately with the specimen form.
10.Document the procedure in the designated place
and mark it off on the Kardex.
Rationale
To prevent the spread of infection
Organisms grow quickly at room temperature
To avoid duplication
Documentation provides coordination of care
165
Purpose:
1. To identify specific pathogens
2. To determine presence of ova and parasites
3. To determine presence of blood and fat
4. To examine for stool characteristics such as color, consistency and odor
Equipments required:
1. Laboratory form
2. Disposable gloves if available (1)
3. Clean bedpan with cover (1)
4. Closed specimen container as ordered
5. Label as required
6. Wooden tongue depressor (1-2)
7. Kidney tray or plastic bag for dirt (1)
Procedure:
Care Action
1. Assemble equipments. Label the container.
Rationale
facilitates
Organization
accurate
skill
performance
Careful labeling ensures accuracy of the report
and alerts the laboratory personnel to the
presence of a contaminated specimen
2. Explanation:
1) Explain the procedure to the client
2) Ask the client to tell you when he/she feels the
urge to have a bowel movement
3. Perform hand hygiene and put on gloves if
available.
4. Placing bedpan:
1) Close door and put curtains/ a screen.
2) Give the bedpan when the client is ready.
3) Allow the client to pass feces
4) Instruct not to contaminate specimen with urine
To provide privacy
You are most likely to obtain a usable specimen at
this time.
To gain accurate results
166
Care Action
5. Collecting a stool specimen:
1) Remove the bedpan and assist the client to clean
if needed
2) Use the tongue depressor to transfer a portion of
the feces to the container without any touching
3) Take a portion of feces from three different areas
of the stool specimen
4) Cover the container
6. Remove and discard gloves. Perform hand
hygiene
7. Send the container immediately to the laboratory
Rationale
It is grossly contaminated
To gain accurate results
It prevents the spread of odor
To prevent the spread of infection
167
Purpose:
1. To diagnose respiratory infection
2. To assess the efficacy of treatment to diseases such as TB
Equipments required:
1. Laboratory form
2. Disposable gloves if available (1)
3. Sterile covered sputum container (1)
4. Label as required
5. Sputum mug or cup (1)
6. Kidney tray or plastic bag for dirt (1)
7. Paper tissues as required
8. Ballpoint pen (1)
Procedure:
Care Action
1. Assemble equipments. Label the container.
Rationale
facilitates
Organization
accurate
skill
performance
Careful labeling ensures accuracy of the report
and alerts the laboratory personnel to the
presence of a contaminated specimen
2. Explain the procedure to the client
Providing information fosters his/her cooperation
3. Perform hand hygiene and put on gloves if To prevent the spread of infection. The sputum
available.
specimen is considered highly contaminated, so
you should treat it with caution.
4. Collecting the specimen:
1) Instruct the client to cough up secretions from A sputum specimen should be from the lungs and
deep in the respiratory passage.
bronchi. It should be sputum rather than
mucous
2) Have the client expectorate directly into the Avoid any chance of outside contamination to the
sterile container.
specimen or any contamination of other objects
3) Instruct the client to wipe around mouth if Paper tissues used by any client are considered
needed. Discard it properly
contaminated
4) Close the specimen immediately
To prevent contamination
5. Remove and discard gloves. Perform hand To prevent contamination of other objects,
hygiene
including the label
6. Send specimen to the laboratory immediately.
To prevent the increase of organisms
7.Document the procedure in the designated place To avoid duplication
and mark it off on the Kardex.
Documentation provides coordination of care
168
Purpose:
1. To detect abnormalities
2. To diagnose disease condition
3. To detect the microorganisms causes respiratory tract infections
4. To treat with specific antibiotics
Equipments required:
1. Laboratory form
2. Disposable gloves if available (1)
3. Sterile covered sputum container (1)
4. Label as required
5. Kidney tray or plastic bag for dirt (1)
6. Paper tissues as required
7. Ballpoint pen (1)
Nursing Alert
You should give proper and understandable explanation to the client
1. Give specimen container on the previous evening with instruction how to treat
2. Instruct to raise sputum from lungs by coughing, not to collect only saliva.
3. Instruct the client to collect the sputum in the morning
4. Instruct the client not to use any antiseptic mouth washes to rinse hid/her mouth before collecting
specimen.
169
Procedure:
Care Action
1. Assemble equipments. Label the container.
Rationale
facilitates
Organization
accurate
skill
performance
Careful labeling ensures accuracy of the report
and alerts the laboratory personnel to the
presence of a contaminated specimen
Providing information fosters his/her cooperation
3. Perform hand hygiene and put on gloves if To prevent the spread of infection. The sputum
available.
specimen is considered highly contaminated, so
you should treat it with caution.
4. Instruct the client:
1) Instruct the client to collect specimen early To obtain overnight accumulated secretions
morning before brushing teeth
2) Instruct the client to remove and place lid facing To maintain the inside of lid as well as inside of
upward.
container
3) Instruct the client to cough deeply and A sputum specimen should be from the lungs and
expectorate directly into specimen container
bronchi. It should be sputum rather than
mucous
4) Instruct the client to expectorate until you collect To obtain accurate results
at least 10 mL of sputum
5) Close the container immediately when sputum To prevent contamination
was collected
6) Instruct the client to wipe around mouth if Paper tissues used by any client are considered
needed. Discard it properly
contaminated
5. Remove and discard gloves. Perform hand
hygiene
6. Send specimen to the laboratory immediately.
7. Document the procedure in the designated place
and mark it off on the Kardex.
170
Appendix 1
Step
Student: (
Instructor: (
)
)
Evaluated on : (
Satisfied
Unsatisfied:
( Put comments )
Not
Performed
Step
Satisfied
172
Unsatisfied:
(Put comments)
Not
Performed
Step
Satisfied
Unsatisfied
Not
Performed
General Comments:
Well performance (
)
Just performed (
)
Poor performance (
Students given poor performance need to receive the back evaluation.
174
Appendix 2
)
)
Evaluated on : (
Satisfied
Step
(by one nurse)
1. Performed hand hygiene
2. Assembled all equipments required and
brought them to bedside
3. Make enough space for bedmaking
4. Cleaned bedside locker by wet and dry
sponge cloth
5. Clean the both side of mattress by wet
and dry sponge cloth
6. Started bedmaking from right side of bed:
1) Apply a bottom sheet and smoothed out it
2) Made a mitered corner in top corner of
bottom sheet and secondly in end corner of
bottom sheet
3) Tucked bottom sheet under mattress
Unsatisfied:
( Put comments )
Not
Performed
Step
(by one nurse)
9. Moved to left side:
1) Pull the top sheet and smoothed it over to
bed
2) Smoothed blanket over to bed
Satisfied
Unsatisfied:
( Put comments )
Not
Performed
General Comments:
Well performance (
)
Just performed (
)
Poor performance (
Students given poor performance need to receive the back evaluation.
176
Appendix 3
)
)
Evaluated on : (
Satisfied
Step
(by one nurse)
1. Confirmed clients identification and
explain the procedures
2.Performed hand hygiene
3. Assembled all equipments required and
brought them to bedside
4. Closed door and/or put screen
5.Removed personal belongings from
bed-side and put them into bedside locker
or safe place. Arranged enough space for
bedmaking
6.Cleaned bedside locker by wet and dry
sponge cloth
7. Loosened top lines from mattress
8. Remove blanket by folding and covered
the clients body by only top sheet
9. Assisted the client to turn toward left side
of the bed. Adjust ed the pillow.
10. Started bedmeaking from right side:
1) Fanfolded (or rolled) soiled lines from the
side of bed and wedged them close to the
client
2) Clean the surface of mattress by wet and
dry sponge cloth
3) Placed bottom sheet evenly on the bed
folded lengthwise with the center fold
4) Adjusted bottom sheet and Mitered a
corner in top corner of bottom sheet
5) Tighten bottom sheet and mitered a
corner in end corner of bottom sheet.
6) Tucked in along side.
7) Place the mackintosh and draw sheet
correctly on the bottom sheet and tucked
them under mattress
11. Assisted client to roll over the folded
linen to right side.
12.Moved to left side:
1) Removed the soiled lines.
2) Discarded the soiled linen correctly.
177
Unsatisfied:
( Put comments )
Not
Performed
Step
(by one nurse)
Satisfied
12.
3) Clean the surface of mattress by wet and
dry sponge cloth
4) Grasped clean linens and pull them out
gently on the mattress
5) Tuck the bottom sheet tightly in top
corner of bed and mitered a corner.
6) Tucked the bottom sheet tightly in end
corner of bed and mitered a corner.
7) Tucked in along side
8) Spread mackintosh and draw sheet over
bottom sheet and tucked them tightly
under mattress.
13. Assisted the client back too the center of
bed. Adjust the pillow.
14. Returned to right side:
1) Placed clean top sheet at the top side of
the soiled top sheet
2) Asked the client to hold the upper edge of
clean top sheet
3) Held both the top of the soiled sheet and
the end of the clean sheet with right hand.
Withdrew to downward.
4) Removed the soiled top sheet and
discarded into laundry bag or bucket.
5) Placed blanket over top sheet correctly.
Made cuff out of top edge of sheet
6) Tucked the lower ends securely under
mattress. Mitered corners.
15. Repeated procedure 14. in left side.
16. Removed the pillow and replace the
pillow cover with clean one. Repositioned
the pillow under clients head.
17. Replaced persona belongings back.
Returned the bed-side locker and bed as
usual
18. Return all equipments to proper places
20. Discarded soiled linens appropriately.
20. Perform hand hygiene.
178
Unsatisfied:
( Put comments )
Not
Performed
General Comments:
Well performance (
)
Just performed (
)
Poor performance (
Students given poor performance need to receive the back evaluation.
179
Appendix 4
Evaluated on : (
Satisfied
)
)
)
Not
Satisfied
Not
done
Remarks
180
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